Provider Demographics
NPI:1275356289
Name:OMNI DENTAL OF SUMTER LLC
Entity type:Organization
Organization Name:OMNI DENTAL OF SUMTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-413-5100
Mailing Address - Street 1:212 OUTLET POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5667
Mailing Address - Country:US
Mailing Address - Phone:803-830-3008
Mailing Address - Fax:
Practice Address - Street 1:625 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8190
Practice Address - Country:US
Practice Address - Phone:803-773-5413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental