Provider Demographics
NPI:1760502181
Name:PROVIDENCE DENTAL GROUP LLC
Entity Type:Organization
Organization Name:PROVIDENCE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:MAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-675-6445
Mailing Address - Street 1:220 BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5700
Mailing Address - Country:US
Mailing Address - Phone:864-675-6445
Mailing Address - Fax:864-675-6447
Practice Address - Street 1:220 BRIDGES RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5700
Practice Address - Country:US
Practice Address - Phone:864-675-6445
Practice Address - Fax:864-675-6447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 3724261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental