1346639457 NPI number — DENTISTRY AT SIMPSONVILLE

Table of content: (NPI 1346639457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346639457 NPI number — DENTISTRY AT SIMPSONVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTISTRY AT SIMPSONVILLE
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:
1346639457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1219 W GEORGIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMPSONVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29680-6335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-228-9112
Provider Business Mailing Address Fax Number:
864-228-9152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1219 W GEORGIA RD
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:
29680-6335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-228-9112
Provider Business Practice Location Address Fax Number:
864-228-9152
Provider Enumeration Date:
01/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
864-228-9112

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3610 , 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: 3610 . This is a "SOUTH CAROLINA STATE BOARD OF DENTISTRY LICENSE NO" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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