1689830226 NPI number — MRS. CHERMAINE LATRICE LYDE DMD

Table of content: MRS. CHERMAINE LATRICE LYDE DMD (NPI 1689830226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689830226 NPI number — MRS. CHERMAINE LATRICE LYDE DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYDE
Provider First Name:
CHERMAINE
Provider Middle Name:
LATRICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTH
Provider Other First Name:
CHERMAINE
Provider Other Middle Name:
LATRICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1689830226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3788
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29230-3788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-733-5969
Provider Business Mailing Address Fax Number:
803-753-5591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8063 EDMUND HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PELION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29123-9805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-894-3736
Provider Business Practice Location Address Fax Number:
803-894-5315
Provider Enumeration Date:
08/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4423 , 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)

  • Identifier: ZX4423 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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