Provider Demographics
NPI:1073967303
Name:SUMMERHILL FAMILY & COSMETIC DENTISTRY, PA
Entity Type:Organization
Organization Name:SUMMERHILL FAMILY & COSMETIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HIEU
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-397-9115
Mailing Address - Street 1:1604 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3067
Mailing Address - Country:US
Mailing Address - Phone:803-279-6743
Mailing Address - Fax:
Practice Address - Street 1:1604 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3067
Practice Address - Country:US
Practice Address - Phone:803-279-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-23
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8561 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8561Medicaid