Provider Demographics
NPI:1659397149
Name:GREAT OAKS DENTAL
Entity Type:Organization
Organization Name:GREAT OAKS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIDDINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,PA
Authorized Official - Phone:864-878-2428
Mailing Address - Street 1:108 MASSINGILL RD
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-2222
Mailing Address - Country:US
Mailing Address - Phone:864-878-2428
Mailing Address - Fax:864-878-3080
Practice Address - Street 1:108 MASSINGILL RD.
Practice Address - Street 2:
Practice Address - City:PICKENS
Practice Address - State:SC
Practice Address - Zip Code:29671-2222
Practice Address - Country:US
Practice Address - Phone:864-878-2428
Practice Address - Fax:864-878-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9767Medicaid