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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