Provider Demographics
NPI:1154476679
Name:PALMETTO DENTAL PA
Entity Type:Organization
Organization Name:PALMETTO DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARAREH
Authorized Official - Middle Name:V
Authorized Official - Last Name:BORHANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-581-2080
Mailing Address - Street 1:701 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-8568
Mailing Address - Country:US
Mailing Address - Phone:803-581-2080
Mailing Address - Fax:803-581-2084
Practice Address - Street 1:701 WILSON ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-8568
Practice Address - Country:US
Practice Address - Phone:803-581-2080
Practice Address - Fax:803-581-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9663Medicaid