Provider Demographics
NPI:1265067987
Name:INDIGO DENTISTRY
Entity type:Organization
Organization Name:INDIGO DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-348-7401
Mailing Address - Street 1:862 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-3434
Mailing Address - Country:US
Mailing Address - Phone:803-348-7401
Mailing Address - Fax:
Practice Address - Street 1:121 ALPINE CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6385
Practice Address - Country:US
Practice Address - Phone:803-348-7401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental