Provider Demographics
NPI:1043699713
Name:114 KERSHAW DENTAL, PC
Entity type:Organization
Organization Name:114 KERSHAW DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-479-1795
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-0330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 E HILTON ST
Practice Address - Street 2:
Practice Address - City:KERSHAW
Practice Address - State:SC
Practice Address - Zip Code:29067-1318
Practice Address - Country:US
Practice Address - Phone:803-475-6052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty