Provider Demographics
NPI:1972650042
Name:BEREA COMPREHENSIVE DENTISTRY
Entity Type:Organization
Organization Name:BEREA COMPREHENSIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIR
Authorized Official - Middle Name:JIM
Authorized Official - Last Name:NASIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-246-2181
Mailing Address - Street 1:701 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-1913
Mailing Address - Country:US
Mailing Address - Phone:864-246-2181
Mailing Address - Fax:
Practice Address - Street 1:701 SULPHUR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-1913
Practice Address - Country:US
Practice Address - Phone:864-246-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9490Medicaid