Provider Demographics
NPI:1629444559
Name:CAROLINA DENTAL DOCS ON-THE-GO, LLC
Entity Type:Organization
Organization Name:CAROLINA DENTAL DOCS ON-THE-GO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NASIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-641-0495
Mailing Address - Street 1:111 POWELL MILL RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-1590
Mailing Address - Country:US
Mailing Address - Phone:864-641-0495
Mailing Address - Fax:
Practice Address - Street 1:112 TOWNPARK DR NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3731
Practice Address - Country:US
Practice Address - Phone:404-410-1340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty