Provider Demographics
NPI:1063775633
Name:PROGRIN DENTAL OF BOILING SPRINGS LLC
Entity type:Organization
Organization Name:PROGRIN DENTAL OF BOILING SPRINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-561-7559
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-0038
Mailing Address - Country:US
Mailing Address - Phone:864-592-1647
Mailing Address - Fax:864-592-0630
Practice Address - Street 1:8810 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-8718
Practice Address - Country:US
Practice Address - Phone:864-592-1647
Practice Address - Fax:864-592-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty