Provider Demographics
NPI:1659561439
Name:HONEA PATH FAMILY DENTISTRY, PA
Entity Type:Organization
Organization Name:HONEA PATH FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-369-2966
Mailing Address - Street 1:322 N SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HONEA PATH
Mailing Address - State:SC
Mailing Address - Zip Code:29654-1636
Mailing Address - Country:US
Mailing Address - Phone:864-369-2966
Mailing Address - Fax:864-369-0666
Practice Address - Street 1:322 N SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-1636
Practice Address - Country:US
Practice Address - Phone:864-369-2966
Practice Address - Fax:864-369-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty