Provider Demographics
NPI:1720246325
Name:JIM NASIM DMD PA
Entity Type:Organization
Organization Name:JIM NASIM DMD PA
Other - Org Name:HALL STREET FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-582-5915
Mailing Address - Street 1:162 HALL ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1524
Mailing Address - Country:US
Mailing Address - Phone:864-582-5915
Mailing Address - Fax:864-582-1076
Practice Address - Street 1:162 HALL ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1524
Practice Address - Country:US
Practice Address - Phone:864-582-5915
Practice Address - Fax:864-582-1076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JIM NASIM DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-30
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
SC2881261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9703Medicaid