Provider Demographics
NPI:1609922517
Name:PARKWAY DENTISTRY OF ANDERSON, LLC
Entity Type:Organization
Organization Name:PARKWAY DENTISTRY OF ANDERSON, LLC
Other - Org Name:ROYAL CREST CENTRE FOR ADVANCED DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MARCELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-225-3763
Mailing Address - Street 1:104 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3334
Mailing Address - Country:US
Mailing Address - Phone:864-225-3763
Mailing Address - Fax:864-225-8486
Practice Address - Street 1:104 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3334
Practice Address - Country:US
Practice Address - Phone:864-225-3763
Practice Address - Fax:864-225-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9525Medicaid