Provider Demographics
NPI:1598115131
Name:CAROLINA FAMILY ORTHODONTICS OF BRUSHY CREEK, LLC
Entity Type:Organization
Organization Name:CAROLINA FAMILY ORTHODONTICS OF BRUSHY CREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ILLSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-282-1935
Mailing Address - Street 1:400 MEMORIAL DRIVE EXT STE 400
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1850
Mailing Address - Country:US
Mailing Address - Phone:864-282-1935
Mailing Address - Fax:864-751-6387
Practice Address - Street 1:1405 BRUSHY CREEK RD
Practice Address - Street 2:BUIDING 2, SUITE A
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4008
Practice Address - Country:US
Practice Address - Phone:864-214-3224
Practice Address - Fax:864-282-1955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FDH HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-14
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty