Provider Demographics
NPI:1730442310
Name:PROGRIN DENTAL OF WOODRUFF LLC
Entity type:Organization
Organization Name:PROGRIN DENTAL OF WOODRUFF 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 1:420 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-2117
Mailing Address - Country:US
Mailing Address - Phone:864-834-8001
Mailing Address - Fax:864-476-0439
Practice Address - Street 1:420 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-2117
Practice Address - Country:US
Practice Address - Phone:864-834-8001
Practice Address - Fax:864-476-0439
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