Provider Demographics
NPI:1598482473
Name:GEORGEA B THEKKETHOTTIYIL LLC
Entity Type:Organization
Organization Name:GEORGEA B THEKKETHOTTIYIL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGEA
Authorized Official - Middle Name:B
Authorized Official - Last Name:THEKKETHOTTIYIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:267-241-8248
Mailing Address - Street 1:109 WINDSORGATE WAY
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3698
Mailing Address - Country:US
Mailing Address - Phone:267-241-8248
Mailing Address - Fax:
Practice Address - Street 1:455 SOUTH BUNCOMBE RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650
Practice Address - Country:US
Practice Address - Phone:267-241-8248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental