Provider Demographics
NPI:1972723815
Name:ALSTON, JEREMIAH MORRIS JR (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:MORRIS
Last Name:ALSTON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-0486
Mailing Address - Country:US
Mailing Address - Phone:803-533-0411
Mailing Address - Fax:803-533-1647
Practice Address - Street 1:1105 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8204
Practice Address - Country:US
Practice Address - Phone:803-533-0411
Practice Address - Fax:803-533-1647
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2448Medicaid