Provider Demographics
NPI:1174739056
Name:CAPITAL CHILDREN'S DENTAL CENTER, LLC
Entity type:Organization
Organization Name:CAPITAL CHILDREN'S DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-951-9100
Mailing Address - Street 1:139 WHITEFORD WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7965
Mailing Address - Country:US
Mailing Address - Phone:803-951-9100
Mailing Address - Fax:803-951-1910
Practice Address - Street 1:655 SAINT ANDREWS RD
Practice Address - Street 2:SUITE 8
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5112
Practice Address - Country:US
Practice Address - Phone:803-252-7725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9467Medicaid