Provider Demographics
NPI:1154657229
Name:VICTORY DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:VICTORY DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CEDRICK
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-547-2280
Mailing Address - Street 1:9787 CHARLOTTE HIGHWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5511
Mailing Address - Country:US
Mailing Address - Phone:803-547-2280
Mailing Address - Fax:803-547-4208
Practice Address - Street 1:9787 CHARLOTTE HIGHWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-5511
Practice Address - Country:US
Practice Address - Phone:803-579-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4382261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental