Provider Demographics
NPI:1568673069
Name:UNIVERSITY DENTAL PA
Entity type:Organization
Organization Name:UNIVERSITY DENTAL PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FELDER MCKELVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-252-8101
Mailing Address - Street 1:PO BOX 50664
Mailing Address - Street 2:2329 DEVINE STREET
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250
Mailing Address - Country:US
Mailing Address - Phone:803-252-8101
Mailing Address - Fax:803-779-7721
Practice Address - Street 1:2329 DEVINE STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29250
Practice Address - Country:US
Practice Address - Phone:803-252-8101
Practice Address - Fax:803-779-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2642122300000X
GADN013211122300000X
VA0401411265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2642Medicaid