Provider Demographics
NPI:1649451410
Name:CAROLINA PROFESSIONAL DENTISTRY,LLC
Entity type:Organization
Organization Name:CAROLINA PROFESSIONAL DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:RESPASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-396-5888
Mailing Address - Street 1:200 DOBYS BRIDGE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-2083
Mailing Address - Country:US
Mailing Address - Phone:803-396-5888
Mailing Address - Fax:803-396-5893
Practice Address - Street 1:200 DOBYS BRIDGE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2083
Practice Address - Country:US
Practice Address - Phone:803-396-5888
Practice Address - Fax:803-396-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty