Provider Demographics
NPI:1073068847
Name:FAMILY DENTISTRY OF EDGEFIELD
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF EDGEFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-637-4616
Mailing Address - Street 1:437 BAUSKETT ST
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-4501
Mailing Address - Country:US
Mailing Address - Phone:803-637-4616
Mailing Address - Fax:888-723-3083
Practice Address - Street 1:437 BAUSKETT ST
Practice Address - Street 2:
Practice Address - City:EDGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-4501
Practice Address - Country:US
Practice Address - Phone:803-637-4616
Practice Address - Fax:888-723-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC47081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty