Provider Demographics
NPI:1851916332
Name:PALMETTO ADVANCED DENTISTRY
Entity Type:Organization
Organization Name:PALMETTO ADVANCED DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIMAVERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-273-3981
Mailing Address - Street 1:1061 ANSLEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 BRIDGEMILL DR STE 100
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-9211
Practice Address - Country:US
Practice Address - Phone:803-848-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental