Provider Demographics
NPI:1164952842
Name:COMPREHENSIVE AND COSMETIC DENTAL STUDIO OF GREENVILLE
Entity Type:Organization
Organization Name:COMPREHENSIVE AND COSMETIC DENTAL STUDIO OF GREENVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-907-4684
Mailing Address - Street 1:644 N MAIN ST STE 111
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1678
Mailing Address - Country:US
Mailing Address - Phone:864-520-2942
Mailing Address - Fax:
Practice Address - Street 1:644 N MAIN ST STE 111
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-1678
Practice Address - Country:US
Practice Address - Phone:864-520-2942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3674261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental