Healthcare Provider Details

I. General information

NPI: 1982913752
Provider Name (Legal Business Name): PARK PLACE DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203B CENTRAL PARK LN
SENECA SC
29678-1156
US

IV. Provider business mailing address

203B CENTRAL PARK LN
SENECA SC
29678-1156
US

V. Phone/Fax

Practice location:
  • Phone: 864-482-2400
  • Fax: 864-482-2404
Mailing address:
  • Phone: 864-482-2400
  • Fax: 864-482-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number8328
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1109
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number493
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4218
License Number StateSC

VIII. Authorized Official

Name: DR. CINDY NICHOLS
Title or Position: DENTIST/ OWNER
Credential:
Phone: 864-482-2400