Provider Demographics
NPI:1073050639
Name:MID-CAROLINA DENTAL CARE, INC
Entity Type:Organization
Organization Name:MID-CAROLINA DENTAL CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-276-2090
Mailing Address - Street 1:2706 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-4004
Mailing Address - Country:US
Mailing Address - Phone:803-276-2090
Mailing Address - Fax:
Practice Address - Street 1:316 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127
Practice Address - Country:US
Practice Address - Phone:803-364-2726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty