Provider Demographics
NPI:1518241710
Name:WILLOUGHBY DENTAL PA
Entity Type:Organization
Organization Name:WILLOUGHBY DENTAL PA
Other - Org Name:WILLOUGHBY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-546-4242
Mailing Address - Street 1:3101 S. HWY 14
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-546-4242
Mailing Address - Fax:
Practice Address - Street 1:3101 S. HWY 14
Practice Address - Street 2:SUITE 4
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-546-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4579261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental