Provider Demographics
NPI:1093081648
Name:ASHBY PARK PEDIATRIC DENTISTRY RIVER FALLS
Entity Type:Organization
Organization Name:ASHBY PARK PEDIATRIC DENTISTRY RIVER FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-433-6888
Mailing Address - Street 1:505 SQUIRES PT
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8867
Mailing Address - Country:US
Mailing Address - Phone:864-433-6888
Mailing Address - Fax:864-433-6889
Practice Address - Street 1:505 SQUIRES PT
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-8867
Practice Address - Country:US
Practice Address - Phone:864-433-6888
Practice Address - Fax:864-433-6889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHBY PARK PEDIATRIC DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-28
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty