Provider Demographics
NPI:1417309956
Name:MARIAN MITCHELL OLIVER CORP.
Entity Type:Organization
Organization Name:MARIAN MITCHELL OLIVER CORP.
Other - Org Name:MCMILLAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-707-8660
Mailing Address - Street 1:939 JC CALHOUN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115
Mailing Address - Country:US
Mailing Address - Phone:803-531-0021
Mailing Address - Fax:
Practice Address - Street 1:939 JC CALHOUN DRIVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-531-0021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MMOC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3333122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC236OtherMEDICARE PTAN
SCZA9906Medicaid