Provider Demographics
NPI:1669838991
Name:PALMS DENTISTRY 225, LLC
Entity Type:Organization
Organization Name:PALMS DENTISTRY 225, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-243-8371
Mailing Address - Street 1:208 HARRISON BRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644
Mailing Address - Country:US
Mailing Address - Phone:864-243-8371
Mailing Address - Fax:864-243-8374
Practice Address - Street 1:208 HARRISON BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644
Practice Address - Country:US
Practice Address - Phone:864-243-8371
Practice Address - Fax:864-243-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty