Provider Demographics
NPI:1225456247
Name:ANCIENT MARINER, LLC
Entity Type:Organization
Organization Name:ANCIENT MARINER, LLC
Other - Org Name:CHILDREN AND ADULT DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-600-7211
Mailing Address - Street 1:7457 PATTERSON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-0710
Mailing Address - Country:US
Mailing Address - Phone:803-807-2140
Mailing Address - Fax:803-807-2141
Practice Address - Street 1:1118 GREENLAWN DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-2606
Practice Address - Country:US
Practice Address - Phone:803-807-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2905261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ29050Medicaid