Provider Demographics
NPI:1982726600
Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
Other - Org Name:CROWFIELD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:102 SPRINGHALL DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5335
Mailing Address - Country:US
Mailing Address - Phone:843-572-8009
Mailing Address - Fax:843-377-0509
Practice Address - Street 1:102 SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5335
Practice Address - Country:US
Practice Address - Phone:843-572-8009
Practice Address - Fax:843-377-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3808Medicaid
SC1393195OtherUNITED CONCORDIA
SCZA9634Medicaid