1467837062 NPI number — INLET PREMIER IMPLANT & COSMETIC DENTISTRY

Table of content: (NPI 1467837062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467837062 NPI number — INLET PREMIER IMPLANT & COSMETIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INLET PREMIER IMPLANT & COSMETIC DENTISTRY
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:
1467837062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9356 HIGHWAY 17 BYP
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MURRELLS INLET
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29576-9328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-421-3198
Provider Business Mailing Address Fax Number:
188-490-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9356 HIGHWAY 17 BYP
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-9328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-421-3198
Provider Business Practice Location Address Fax Number:
188-490-5080
Provider Enumeration Date:
07/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HODGES
Authorized Official First Name:
TAUREAN
Authorized Official Middle Name:
JERMAINE
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
843-421-3198

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4675 , 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: ZX4675 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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