Provider Demographics
NPI:1417309451
Name:ASHBY PARK PEDIATRIC DENTISTRY EASLEY
Entity Type:Organization
Organization Name:ASHBY PARK PEDIATRIC DENTISTRY EASLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-234-3424
Mailing Address - Street 1:708 NORTH A STREET
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640
Mailing Address - Country:US
Mailing Address - Phone:864-605-7741
Mailing Address - Fax:
Practice Address - Street 1:708 NORTH A STREET
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-605-7741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHBY PARK PEDIATRIC DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36381223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty