Provider Demographics
NPI:1679767073
Name:VILLAGE DENTISTRY, PA
Entity Type:Organization
Organization Name:VILLAGE DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-768-8376
Mailing Address - Street 1:130 GARDNERS CIR
Mailing Address - Street 2:PMB#131
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-5467
Mailing Address - Country:US
Mailing Address - Phone:843-768-8376
Mailing Address - Fax:
Practice Address - Street 1:130 GARDNERS CIR
Practice Address - Street 2:PMB#131
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-5467
Practice Address - Country:US
Practice Address - Phone:843-768-8376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1688261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental