Provider Demographics
NPI:1083008890
Name:HOLLY TREE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:HOLLY TREE PEDIATRIC DENTISTRY
Other - Org Name:HOLLY TREE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-297-5585
Mailing Address - Street 1:1334 HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5659
Mailing Address - Country:US
Mailing Address - Phone:864-297-5585
Mailing Address - Fax:864-297-4166
Practice Address - Street 1:1334 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5659
Practice Address - Country:US
Practice Address - Phone:864-297-5585
Practice Address - Fax:864-297-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34271223P0221X
SC3433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty