Provider Demographics
NPI:1326332628
Name:CAROLINA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:CAROLINA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:SPIVEY
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-585-8558
Mailing Address - Street 1:763 E. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302
Mailing Address - Country:US
Mailing Address - Phone:864-585-8558
Mailing Address - Fax:864-580-4242
Practice Address - Street 1:763 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302
Practice Address - Country:US
Practice Address - Phone:864-585-8558
Practice Address - Fax:864-580-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3703261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3703Medicaid