Provider Demographics
NPI:1811405400
Name:PRIME PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:PRIME PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOUROGYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-536-9888
Mailing Address - Street 1:2420 HOFFMEYER RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-7426
Mailing Address - Country:US
Mailing Address - Phone:843-536-9888
Mailing Address - Fax:
Practice Address - Street 1:2420 HOFFMEYER RD UNIT A
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-7426
Practice Address - Country:US
Practice Address - Phone:843-536-9888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental