Basic Information
| Provider Information | |||||||||
| NPI: | 1306811914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDIVER | ||||||||
| FirstName: | TERRENCE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 GORDON HWY | ||||||||
| Address2: | #22 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067909303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 GORDON HWY | ||||||||
| Address2: | #22 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309062292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067909302 | ||||||||
| FaxNumber: | 7067909303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN012433 | GA | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 3827 | SC | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZX3827 | 05 | SC | MEDICAID | 747629278A | 05 | GA | MEDICAID | 9180178 | 01 | GA | DENTAQUEST | OTHER | 2670243 | 01 | GA | UNITED CONCORDIA | OTHER |