Provider Demographics
NPI:1013484484
Name:PREMIER SMILE CENTER
Entity Type:Organization
Organization Name:PREMIER SMILE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENNELL
Authorized Official - Middle Name:SIRECIA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-626-1265
Mailing Address - Street 1:7212 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-2202
Mailing Address - Country:US
Mailing Address - Phone:803-626-1265
Mailing Address - Fax:803-281-8832
Practice Address - Street 1:7212 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2202
Practice Address - Country:US
Practice Address - Phone:803-626-1265
Practice Address - Fax:803-281-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6936OtherDENTEST REGISTRATION