Basic Information
| Provider Information | |||||||||
| NPI: | 1053083154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIDENT DENTAL ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746689 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153767600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 9228 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435745693 | ||||||||
| FaxNumber: | 8437644512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153723375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.