Provider Demographics
NPI:1073647889
Name:FLEETWOOD DENTAL
Entity Type:Organization
Organization Name:FLEETWOOD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:ELY
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-855-2788
Mailing Address - Street 1:105 FLEETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2019
Mailing Address - Country:US
Mailing Address - Phone:864-855-2788
Mailing Address - Fax:864-855-2789
Practice Address - Street 1:105 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2019
Practice Address - Country:US
Practice Address - Phone:864-855-2788
Practice Address - Fax:864-855-2789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty