Provider Demographics
NPI:1407918014
Name:PRIME DENTAL OF WOODRUFF
Entity Type:Organization
Organization Name:PRIME DENTAL OF WOODRUFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASA
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-834-8001
Mailing Address - Street 1:420 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-2117
Mailing Address - Country:US
Mailing Address - Phone:864-476-3212
Mailing Address - Fax:864-476-3212
Practice Address - Street 1:420 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-2117
Practice Address - Country:US
Practice Address - Phone:864-476-3212
Practice Address - Fax:864-476-3212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9487Medicaid