Provider Demographics
NPI:1801453675
Name:ELITE SMILES DENTAL, PA
Entity type:Organization
Organization Name:ELITE SMILES DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:GAMBRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-419-5002
Mailing Address - Street 1:9020 FARROW RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9773
Mailing Address - Country:US
Mailing Address - Phone:803-419-5002
Mailing Address - Fax:803-419-9600
Practice Address - Street 1:9020 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9773
Practice Address - Country:US
Practice Address - Phone:803-419-5002
Practice Address - Fax:803-419-9600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE SMILES DENTAL, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-28
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies