Provider Demographics
NPI:1952588824
Name:GILLIAM FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GILLIAM FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE STAFF
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-286-5858
Mailing Address - Street 1:208 E DUNLAP ST
Mailing Address - Street 2:P.O. BOX 1114
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-2511
Mailing Address - Country:US
Mailing Address - Phone:803-286-5858
Mailing Address - Fax:803-313-9650
Practice Address - Street 1:208 E DUNLAP ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2511
Practice Address - Country:US
Practice Address - Phone:803-286-5858
Practice Address - Fax:803-313-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9811Medicaid