1598088312 NPI number — WENTWORTH STREET DENTAL ASSOCIATES, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598088312 NPI number — WENTWORTH STREET DENTAL ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WENTWORTH STREET DENTAL ASSOCIATES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598088312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 WENTWORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29401-6715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-577-2898
Provider Business Mailing Address Fax Number:
843-577-4464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 WENTWORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29401-6715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-577-2898
Provider Business Practice Location Address Fax Number:
843-577-4464
Provider Enumeration Date:
03/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
REEVES
Authorized Official First Name:
ROGERS
Authorized Official Middle Name:
CONYERS
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
843-577-2898

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  1547 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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