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Organization
ANCIENT MARINER, LLC
Active
Organization
ANCIENT MARINER, LLC
Active
Other names
Children and Adult Dental Group
Organization subpart
No
Provider details
NPI number
Authorized official
TONIA PATTERSON (OFFICE ADMINISTRATOR)
(803) 600-7211
Entity
Organization
Contact information
Practice address
1118 GREENLAWN DR, COLUMBIA, SC 29209-2606
(803) 807-2140
Mailing address
7457 PATTERSON RD STE 107, COLUMBIA, SC 29209-0710
(803) 807-2140
(803) 807-2141
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
2905
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Z29050
—
SC
Enumeration date
04/07/2014
Last updated
10/27/2015
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