Provider Demographics
NPI:1275780454
Name:UPSTATE PEDIATRIC DENTISTRY, PA
Entity Type:Organization
Organization Name:UPSTATE PEDIATRIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-676-9873
Mailing Address - Street 1:105-A HALTON ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3507
Mailing Address - Country:US
Mailing Address - Phone:864-676-9873
Mailing Address - Fax:864-676-9870
Practice Address - Street 1:105-A HALTON ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3507
Practice Address - Country:US
Practice Address - Phone:864-676-9873
Practice Address - Fax:864-676-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty