Provider Demographics
NPI:1306811914
Name:VANDIVER, TERRENCE L
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:L
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 GORDON HWY
Mailing Address - Street 2:#22
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2292
Mailing Address - Country:US
Mailing Address - Phone:706-790-9302
Mailing Address - Fax:706-790-9303
Practice Address - Street 1:1631 GORDON HWY
Practice Address - Street 2:#22
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2292
Practice Address - Country:US
Practice Address - Phone:706-790-9302
Practice Address - Fax:706-790-9303
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124331223G0001X
SC38271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3827Medicaid
GA747629278AMedicaid
GA9180178OtherDENTAQUEST
GA2670243OtherUNITED CONCORDIA