Provider Demographics
NPI:1255384038
Name:CALCUTT, RONALD BRENT JR (DMD, PA)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:BRENT
Last Name:CALCUTT
Suffix:JR
Gender:M
Credentials:DMD, PA
Other - Prefix:DR
Other - First Name:RON
Other - Middle Name:B
Other - Last Name:CALCUTT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DMD,PA
Mailing Address - Street 1:508 WALKINGSTICK WAY
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7216
Mailing Address - Country:US
Mailing Address - Phone:864-228-7297
Mailing Address - Fax:
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1611
Practice Address - Country:US
Practice Address - Phone:864-862-2966
Practice Address - Fax:864-862-2112
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9535Medicaid