Provider Demographics
NPI: | 1134311830 |
---|---|
Name: | DR. KEITH B. FLYNN DMD PA |
Entity Type: | Organization |
Organization Name: | DR. KEITH B. FLYNN DMD PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KEITH |
Authorized Official - Middle Name: | BRYAN |
Authorized Official - Last Name: | FLYNN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 843-824-8742 |
Mailing Address - Street 1: | 1505 RED BANK RD |
Mailing Address - Street 2: | |
Mailing Address - City: | GOOSE CREEK |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29445-4516 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-824-8742 |
Mailing Address - Fax: | 843-824-8430 |
Practice Address - Street 1: | 1505 RED BANK RD |
Practice Address - Street 2: | |
Practice Address - City: | GOOSE CREEK |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29445-4516 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-824-8742 |
Practice Address - Fax: | 843-824-8430 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-08-16 |
Last Update Date: | 2007-08-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 3106 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |