Provider Demographics
NPI:1154665776
Name:IMMEDIATE DENTAL GROUP LLC - NORTH CHARLESTON
Entity Type:Organization
Organization Name:IMMEDIATE DENTAL GROUP LLC - NORTH CHARLESTON
Other - Org Name:IMMEDIATE DENTAL GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-480-9500
Mailing Address - Street 1:5900 RIVERS AVE
Mailing Address - Street 2:UNIT X
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6054
Mailing Address - Country:US
Mailing Address - Phone:843-480-5900
Mailing Address - Fax:843-480-9502
Practice Address - Street 1:5900 RIVERS AVE
Practice Address - Street 2:UNIT X
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6054
Practice Address - Country:US
Practice Address - Phone:843-480-5900
Practice Address - Fax:843-480-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty