Provider Demographics
NPI:1013220391
Name:TOOTH ZONE - ZONA DIENTES
Entity Type:Organization
Organization Name:TOOTH ZONE - ZONA DIENTES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:L.C.C.'S MEMBER & PRESIDENT/GENERAL
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:NICK
Authorized Official - Last Name:BOBOTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-329-5400
Mailing Address - Street 1:103 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611
Mailing Address - Country:US
Mailing Address - Phone:864-295-3086
Mailing Address - Fax:864-295-3286
Practice Address - Street 1:103 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611
Practice Address - Country:US
Practice Address - Phone:864-295-3086
Practice Address - Fax:864-295-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ34909Medicaid