Provider Demographics
NPI:1629621933
Name:PRIME DENTAL LLC
Entity Type:Organization
Organization Name:PRIME DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ASA
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-332-1266
Mailing Address - Street 1:4130 CLEMSON BLVD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621
Mailing Address - Country:US
Mailing Address - Phone:864-332-1266
Mailing Address - Fax:864-332-1266
Practice Address - Street 1:4130 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-332-1266
Practice Address - Fax:864-261-6988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2657Other-
SC218632Medicaid