Provider Demographics
NPI:1093180283
Name:PICKENS FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:PICKENS FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MACRAE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-878-3501
Mailing Address - Street 1:829 PENDLETON ST
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-2578
Mailing Address - Country:US
Mailing Address - Phone:864-878-3501
Mailing Address - Fax:864-878-3502
Practice Address - Street 1:829 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:PICKENS
Practice Address - State:SC
Practice Address - Zip Code:29671-2578
Practice Address - Country:US
Practice Address - Phone:864-878-3501
Practice Address - Fax:864-878-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1407947534OtherNPI