Provider Demographics
NPI:1801297783
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:3308 PLATT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2204
Mailing Address - Country:US
Mailing Address - Phone:803-796-7934
Mailing Address - Fax:803-796-1357
Practice Address - Street 1:3308 PLATT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-2204
Practice Address - Country:US
Practice Address - Phone:803-796-7934
Practice Address - Fax:803-796-1357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty