Provider Demographics
NPI:1336502632
Name:JEBEDIAH S. CHRISTY, D.D.S - CONWAY, PLLC
Entity Type:Organization
Organization Name:JEBEDIAH S. CHRISTY, D.D.S - CONWAY, PLLC
Other - Org Name:ASPEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEBEDIAH
Authorized Official - Middle Name:SHEPHERD
Authorized Official - Last Name:CHRISTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-438-4210
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:315-410-5531
Practice Address - Street 1:2756 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-438-4210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty