Provider Demographics
NPI:1104467224
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 1:2749 AGNES LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2029
Mailing Address - Country:US
Mailing Address - Phone:843-491-4378
Mailing Address - Fax:
Practice Address - Street 1:2749 AGNES LN
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-2029
Practice Address - Country:US
Practice Address - Phone:843-213-6653
Practice Address - Fax:843-492-5993
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-30
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty