Provider Demographics
NPI:1891826327
Name:SOUTH CAROLINA COMMUNITY DENTISTRY SERVICE
Entity Type:Organization
Organization Name:SOUTH CAROLINA COMMUNITY DENTISTRY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-344-0304
Mailing Address - Street 1:701 GERVAIS ST
Mailing Address - Street 2:#150-128
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3066
Mailing Address - Country:US
Mailing Address - Phone:888-344-0304
Mailing Address - Fax:
Practice Address - Street 1:701 GERVAIS ST
Practice Address - Street 2:#150-128
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3066
Practice Address - Country:US
Practice Address - Phone:888-344-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9625Medicaid