Provider Demographics
NPI:1235685843
Name:CEDAR DRIVE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CEDAR DRIVE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-567-3175
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHEN
Mailing Address - State:SC
Mailing Address - Zip Code:29479-0760
Mailing Address - Country:US
Mailing Address - Phone:843-567-3175
Mailing Address - Fax:843-567-3293
Practice Address - Street 1:133 CEDAR DRIVE
Practice Address - Street 2:
Practice Address - City:SAINT STEPHEN
Practice Address - State:SC
Practice Address - Zip Code:29479
Practice Address - Country:US
Practice Address - Phone:843-567-3175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty