Provider Demographics
NPI:1588407340
Name:DENTRUST DENTAL SOUTH CAROLINA PC
Entity type:Organization
Organization Name:DENTRUST DENTAL SOUTH CAROLINA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-927-5000
Mailing Address - Street 1:1221 VINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-4829
Mailing Address - Country:US
Mailing Address - Phone:813-451-4503
Mailing Address - Fax:
Practice Address - Street 1:4712 LIBERTY DIVISION AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5405
Practice Address - Country:US
Practice Address - Phone:803-334-0530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty