Provider Demographics
NPI:1942261110
Name:MIDLANDS DENTAL GROUP, P.L.
Entity Type:Organization
Organization Name:MIDLANDS DENTAL GROUP, P.L.
Other - Org Name:DRS. ELLIS GREEN AND GREEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-788-9593
Mailing Address - Street 1:8905 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6367
Mailing Address - Country:US
Mailing Address - Phone:803-788-9593
Mailing Address - Fax:803-788-3123
Practice Address - Street 1:8905 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6367
Practice Address - Country:US
Practice Address - Phone:803-788-9593
Practice Address - Fax:803-788-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9724Medicaid