Provider Demographics
NPI:1033593314
Name:SUPREME DENTAL HOSPITAL SERVICES
Entity Type:Organization
Organization Name:SUPREME DENTAL HOSPITAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:LOLADE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL-CASH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-465-2210
Mailing Address - Street 1:307 N. GREENE ST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 N. GREENE ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2182
Practice Address - Country:US
Practice Address - Phone:704-465-2210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223G0001X261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental