Provider Demographics
NPI:1467898403
Name:PALMETTO DENTISTRY, LLC
Entity Type:Organization
Organization Name:PALMETTO DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIX
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-259-7645
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-0846
Mailing Address - Country:US
Mailing Address - Phone:803-259-7645
Mailing Address - Fax:
Practice Address - Street 1:53 IRVING ST
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-1535
Practice Address - Country:US
Practice Address - Phone:803-259-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty