1295344646 NPI number — SEA GLASS PERIODONTICS OF SIMPSONVILLE LLC

Table of content: (NPI 1295344646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295344646 NPI number — SEA GLASS PERIODONTICS OF SIMPSONVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEA GLASS PERIODONTICS OF SIMPSONVILLE LLC
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:
1295344646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 MEMORIAL DRIVE EXT STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29651-1850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-282-1935
Provider Business Mailing Address Fax Number:
864-751-6387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110A HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29681-3226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-757-8820
Provider Business Practice Location Address Fax Number:
864-751-6387
Provider Enumeration Date:
07/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
ILLSLEY
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF INSURANCE
Authorized Official Telephone Number:
864-282-1935

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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