Provider Demographics
NPI:1982736088
Name:BISHOP, IVAN ANDERSON JR (DDS)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ANDERSON
Last Name:BISHOP
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 JILL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059-2512
Mailing Address - Country:US
Mailing Address - Phone:803-496-9695
Mailing Address - Fax:803-496-5093
Practice Address - Street 1:912 HOLLY STREET
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-0606
Practice Address - Country:US
Practice Address - Phone:803-496-5093
Practice Address - Fax:803-496-5093
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice