Provider Demographics
NPI:1811968159
Name:DS DENTAL, LLC
Entity type:Organization
Organization Name:DS DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:SPIGUZZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-220-0620
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569
Mailing Address - Country:US
Mailing Address - Phone:843-756-2273
Mailing Address - Fax:843-756-0242
Practice Address - Street 1:4004 BAYBORO ST.
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569
Practice Address - Country:US
Practice Address - Phone:843-756-2273
Practice Address - Fax:843-756-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9575Medicaid