Provider Demographics
NPI:1619423449
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Other - Org Name:DENTAL CARE OF LAKE WYLIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:209 LATITUDE LANE
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:803-619-4511
Mailing Address - Fax:803-619-4586
Practice Address - Street 1:209 LATITUDE LANE
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710
Practice Address - Country:US
Practice Address - Phone:803-619-4511
Practice Address - Fax:803-619-4586
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-31
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty