Provider Demographics
NPI:1962830216
Name:HEAD DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:HEAD DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-673-4788
Mailing Address - Street 1:1483 TOBIAS GADSON BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-8702
Mailing Address - Country:US
Mailing Address - Phone:843-556-3838
Mailing Address - Fax:843-556-4325
Practice Address - Street 1:1483 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-8702
Practice Address - Country:US
Practice Address - Phone:843-556-3838
Practice Address - Fax:843-556-4325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8070261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental