NPI |
1053083154 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider Organization Name Legal Business Name |
TRIDENT DENTAL ASSOCIATES, LLC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider First Line Business Practice Location Address |
9228 MEDICAL PLAZA DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
CHARLESTON |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
SC |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
294069125 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
8435745693 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
Provider Business Practice Location Address Fax Number |
8437644512 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider Enumeration Date |
9/28/2021 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
8/29/2023 |
The first name of the provider, if the provider
is an individual. |
Authorized Official Last Name |
JOHNSON |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Authorized Official First Name |
WILLIAM |
The first name of the authorized official. |
Authorized Official Middle Name |
TEDERICK |
The State code in the location of the provider
being identified. |
Authorized Official Title or Position |
GROUP VICE PRESIDENT/AO |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Authorized Official Telephone Number |
6153723375 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
1223S0112X |
The telephone number associated with the location address of the provider being identified. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
The date the provider was assigned a unique identifier (assigned an NPI). |
Is Organization Subpart |
N |
|
Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
The code designating the provider’s gender if the provider is a person. |
NPI Certification Date |
8/29/2023 |
|