Basic Information
Provider Information | |||||||||
NPI: | 1316036676 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALMETTO DENTAL ARTS, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 347 RED CEDAR ST | ||||||||
Address2: | BUILDING 400 | ||||||||
City: | BLUFFTON | ||||||||
State: | SC | ||||||||
PostalCode: | 299108906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438156500 | ||||||||
FaxNumber: | 8438156501 | ||||||||
Practice Location | |||||||||
Address1: | 347 RED CEDAR ST | ||||||||
Address2: | BUILDING 400 | ||||||||
City: | BLUFFTON | ||||||||
State: | SC | ||||||||
PostalCode: | 299108906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438156500 | ||||||||
FaxNumber: | 8438156501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DENTIST | ||||||||
AuthorizedOfficialTelephone: | 8438156500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 3555 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.