Provider Demographics
NPI:1477806206
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA
Other - Org Name:GENTLE DENTAL CARE OF NORTH MYRTLE BEACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1004 SEA MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2211
Mailing Address - Country:US
Mailing Address - Phone:843-280-7776
Mailing Address - Fax:843-280-9864
Practice Address - Street 1:1004 SEA MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2211
Practice Address - Country:US
Practice Address - Phone:843-280-7776
Practice Address - Fax:843-280-9864
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF SOUTH CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty