Provider Demographics
NPI:1760664304
Name:DISTINCTIVE DENTISTRY
Entity Type:Organization
Organization Name:DISTINCTIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-917-6962
Mailing Address - Street 1:11107 BROAD RIVER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7602
Mailing Address - Country:US
Mailing Address - Phone:803-749-3980
Mailing Address - Fax:803-749-3981
Practice Address - Street 1:11107 BROAD RIVER RD
Practice Address - Street 2:SUITE D
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7602
Practice Address - Country:US
Practice Address - Phone:803-749-3980
Practice Address - Fax:803-749-3981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty