Provider Demographics
NPI:1316076516
Name:PEE DEE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:PEE DEE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HARTWELL
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-667-6660
Mailing Address - Street 1:1423 ALICE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-2660
Mailing Address - Country:US
Mailing Address - Phone:843-667-6660
Mailing Address - Fax:843-661-0836
Practice Address - Street 1:1423 ALICE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-2660
Practice Address - Country:US
Practice Address - Phone:843-667-6660
Practice Address - Fax:843-661-0836
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEE DEE PEDIATRIC DENTISTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9697Medicaid