Provider Demographics
NPI:1194026310
Name:BEREA DENTAL CARE LLC
Entity Type:Organization
Organization Name:BEREA DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-235-3949
Mailing Address - Street 1:1906 CEDAR LANE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-1733
Mailing Address - Country:US
Mailing Address - Phone:864-235-3949
Mailing Address - Fax:
Practice Address - Street 1:1906 CEDAR LANE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-1733
Practice Address - Country:US
Practice Address - Phone:864-235-3949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC44791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty