Basic Information
| Provider Information | |||||||||
| NPI: | 1114665619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMETTO DENTAL ARTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 347 RED CEDAR ST BLDG 400 | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156500 | ||||||||
| FaxNumber: | 8438156501 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 RED CEDAR ST BLDG 400 | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156500 | ||||||||
| FaxNumber: | 8438156501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | EVANS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8438166566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.