Provider Demographics
NPI:1346406733
Name:MIDLANDS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MIDLANDS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICKBORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-731-0803
Mailing Address - Street 1:2844 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3420
Mailing Address - Country:US
Mailing Address - Phone:803-731-0803
Mailing Address - Fax:
Practice Address - Street 1:2844 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3420
Practice Address - Country:US
Practice Address - Phone:803-731-0803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC23451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty