Provider Demographics
NPI:1811377120
Name:PALMETTO FAMILY DENTISTRY OF ANDERSON, LLC
Entity Type:Organization
Organization Name:PALMETTO FAMILY DENTISTRY OF ANDERSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-226-8272
Mailing Address - Street 1:2713 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3282
Mailing Address - Country:US
Mailing Address - Phone:864-226-8272
Mailing Address - Fax:864-964-9538
Practice Address - Street 1:2713 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3282
Practice Address - Country:US
Practice Address - Phone:864-226-8272
Practice Address - Fax:864-964-9538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3611122300000X
SC4399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9700Medicaid