Provider Demographics
NPI:1134663784
Name:FOREST DRIVE DENTAL CARE, P.A.
Entity Type:Organization
Organization Name:FOREST DRIVE DENTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:SILVER
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-782-8786
Mailing Address - Street 1:3731 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4007
Mailing Address - Country:US
Mailing Address - Phone:803-782-8786
Mailing Address - Fax:803-782-6682
Practice Address - Street 1:3731 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4007
Practice Address - Country:US
Practice Address - Phone:803-782-8786
Practice Address - Fax:803-782-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4660Medicaid