Provider Demographics
NPI:1043827314
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Other - Org Name:WEDGEWOOD SQUARE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1767 HECKLE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1878
Mailing Address - Country:US
Mailing Address - Phone:803-992-8531
Mailing Address - Fax:
Practice Address - Street 1:1767 HECKLE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1878
Practice Address - Country:US
Practice Address - Phone:803-992-8531
Practice Address - Fax:803-980-8873
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-30
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty