Provider Demographics
NPI:1619455417
Name:EH DENTAL, LLC
Entity Type:Organization
Organization Name:EH DENTAL, LLC
Other - Org Name:EAST HIGHLAND DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-226-5058
Mailing Address - Street 1:303 E HIGHLAND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4767
Mailing Address - Country:US
Mailing Address - Phone:864-226-5058
Mailing Address - Fax:
Practice Address - Street 1:303 E HIGHLAND AVE STE 105
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4767
Practice Address - Country:US
Practice Address - Phone:864-226-5058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851834964Medicaid