Provider Demographics
NPI:1578034369
Name:DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2373 LEN PATTERSON RD STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8266
Mailing Address - Country:US
Mailing Address - Phone:803-752-0655
Mailing Address - Fax:803-396-0029
Practice Address - Street 1:2373 LEN PATTERSON RD STE 103
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8266
Practice Address - Country:US
Practice Address - Phone:803-310-6109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-06
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty