Provider Demographics
NPI:1114497963
Name:FAMILY DENTAL HEALTH OF HALTON ROAD, LLC
Entity Type:Organization
Organization Name:FAMILY DENTAL HEALTH OF HALTON ROAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ILLSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-282-1935
Mailing Address - Street 1:110 VILLA RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3010
Mailing Address - Country:US
Mailing Address - Phone:864-282-1935
Mailing Address - Fax:864-751-6387
Practice Address - Street 1:155 HALTON VILLAGE CIR STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6825
Practice Address - Country:US
Practice Address - Phone:864-289-9752
Practice Address - Fax:864-751-6387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FDH HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty