Provider Demographics
NPI:1689830226
Name:LYDE, CHERMAINE LATRICE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:CHERMAINE
Middle Name:LATRICE
Last Name:LYDE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CHERMAINE
Other - Middle Name:LATRICE
Other - Last Name:RUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 3788
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3788
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:8063 EDMUND HWY
Practice Address - Street 2:
Practice Address - City:PELION
Practice Address - State:SC
Practice Address - Zip Code:29123-9805
Practice Address - Country:US
Practice Address - Phone:803-894-3736
Practice Address - Fax:803-894-5315
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4423Medicaid
SCSC4250Medicare UPIN