Provider Demographics
NPI:1932376035
Name:LIBERTY DENTAL CARE, INC.
Entity Type:Organization
Organization Name:LIBERTY DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-843-3742
Mailing Address - Street 1:207 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-1009
Mailing Address - Country:US
Mailing Address - Phone:864-843-3742
Mailing Address - Fax:864-843-3744
Practice Address - Street 1:207 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1009
Practice Address - Country:US
Practice Address - Phone:864-843-3742
Practice Address - Fax:864-843-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3144261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ31449Medicaid