Healthcare Provider Details

I. General information

NPI: 1316315054
Provider Name (Legal Business Name): JIM NASIM DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 W CHEROKEE ST
BLACKSBURG SC
29702-9221
US

IV. Provider business mailing address

1119 W CHEROKEE ST
BLACKSBURG SC
29702-9221
US

V. Phone/Fax

Practice location:
  • Phone: 864-839-0034
  • Fax: 864-839-0064
Mailing address:
  • Phone: 864-839-0034
  • Fax: 864-839-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2881
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2881
License Number StateSC

VIII. Authorized Official

Name: JENNI TOMLINSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 864-839-0034