Provider Demographics
NPI:1679760870
Name:FOOTHILLS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:FOOTHILLS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-578-9040
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:SC
Mailing Address - Zip Code:29368-0860
Mailing Address - Country:US
Mailing Address - Phone:864-578-9040
Mailing Address - Fax:
Practice Address - Street 1:3480 CHESNEE HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29368
Practice Address - Country:US
Practice Address - Phone:864-578-9040
Practice Address - Fax:864-578-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903567Medicaid
ND5906513Medicaid
SCZA9657Medicaid