Basic Information
| Provider Information | |||||||||
| NPI: | 1740334911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISMA HEALTH-MIDLANDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5301 | ||||||||
| Address2: | PALMETTO HEALTH DENTAL CLINIC | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292505301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | PALMETTO HEALTH DENTAL CLINIC | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PAYOR STRATEGIES ALIGNMENT | ||||||||
| AuthorizedOfficialTelephone: | 8645222286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRISMA HEALTH DENTAL CLINIC | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.