Provider Demographics
NPI:1609353606
Name:PRIMAVERA, ALBERT ANTHONY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:ANTHONY
Last Name:PRIMAVERA
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 ANSLEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7885
Mailing Address - Country:US
Mailing Address - Phone:239-273-3981
Mailing Address - Fax:
Practice Address - Street 1:2021 BRIDGEMILL DR STE 100
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-9211
Practice Address - Country:US
Practice Address - Phone:803-848-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC111561223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice