Provider Demographics
NPI:1144300708
Name:GREENVILLE SMILES P.A.
Entity type:Organization
Organization Name:GREENVILLE SMILES P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-244-7135
Mailing Address - Street 1:140 MALL CONNECTOR RD
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607
Mailing Address - Country:US
Mailing Address - Phone:864-244-7135
Mailing Address - Fax:864-268-2428
Practice Address - Street 1:140 MALL CONNECTOR RD
Practice Address - Street 2:SUITE 6A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-244-7135
Practice Address - Fax:864-268-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9622Medicaid
SCZA9622Medicaid