Provider Demographics
NPI:1043630437
Name:CDA DENTAL PA
Entity Type:Organization
Organization Name:CDA DENTAL PA
Other - Org Name:LYMAN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-406-3678
Mailing Address - Street 1:301 SPARTANBURG RD
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-1746
Mailing Address - Country:US
Mailing Address - Phone:864-439-1240
Mailing Address - Fax:
Practice Address - Street 1:301 SPARTANBURG RD
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1746
Practice Address - Country:US
Practice Address - Phone:864-439-1240
Practice Address - Fax:864-439-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX6942Medicaid