Provider Demographics
NPI:1295405819
Name:FT MILL DENTISTRY LLC
Entity Type:Organization
Organization Name:FT MILL DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-547-7508
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-0489
Mailing Address - Country:US
Mailing Address - Phone:803-547-7508
Mailing Address - Fax:803-547-1070
Practice Address - Street 1:133 CLEBOURNE ST
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-1742
Practice Address - Country:US
Practice Address - Phone:803-547-7508
Practice Address - Fax:803-547-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4178OtherSOUTH CAROLINA BOARD OF DENTISTRY
SC4481OtherSOUTH CAROLINA BOARD OF DENTISTRY