Provider Demographics
NPI:1205389681
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Other - Org Name:KILLIAN ROAD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:460 KILLIAN ROAD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-814-0102
Mailing Address - Fax:803-814-2225
Practice Address - Street 1:460 KILLIAN ROAD
Practice Address - Street 2:UNIT 1
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-753-4754
Practice Address - Fax:803-814-2225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-02
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty