Provider Demographics
NPI:1922301639
Name:AUGUSTA STREET DENTAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:AUGUSTA STREET DENTAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYWANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROCE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-232-8393
Mailing Address - Street 1:111 WHISPERING PINES LANE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646
Mailing Address - Country:US
Mailing Address - Phone:864-232-8393
Mailing Address - Fax:864-242-6944
Practice Address - Street 1:813 AUGUSTA STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-232-8393
Practice Address - Fax:864-242-6944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty