Provider Demographics
NPI:1790196368
Name:COMPASS DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:COMPASS DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-200-1999
Mailing Address - Street 1:2801 WADE HAMPTON BLVD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 WADE HAMPTON BLVD
Practice Address - Street 2:SUITE 118
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2781
Practice Address - Country:US
Practice Address - Phone:864-715-0688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4024Medicaid