Provider Demographics
NPI:1063689503
Name:PALMETTO DENTURE CARE PA
Entity Type:Organization
Organization Name:PALMETTO DENTURE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:JUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-582-4308
Mailing Address - Street 1:975 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4104
Mailing Address - Country:US
Mailing Address - Phone:864-582-4308
Mailing Address - Fax:864-596-4492
Practice Address - Street 1:975 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-582-4308
Practice Address - Fax:864-596-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9415Medicaid
NC5950162Medicaid