Provider Demographics
NPI:1164583183
Name:C FRED MARCINAK DMD PA
Entity Type:Organization
Organization Name:C FRED MARCINAK DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:MARCINAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-638-7228
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:WALHALLA
Mailing Address - State:SC
Mailing Address - Zip Code:29691
Mailing Address - Country:US
Mailing Address - Phone:864-638-7228
Mailing Address - Fax:864-718-7162
Practice Address - Street 1:102 LUSK DRIVE
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:SC
Practice Address - Zip Code:29696
Practice Address - Country:US
Practice Address - Phone:864-638-7228
Practice Address - Fax:864-718-7162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC002195Medicaid