Provider Demographics
NPI: | 1790422137 |
---|---|
Name: | FAMILY DENTAL HEALTH OF CREEKSIDE LLC |
Entity Type: | Organization |
Organization Name: | FAMILY DENTAL HEALTH OF CREEKSIDE LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR OF INSURANCE |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | BETH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ILLSLEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 864-282-1935 |
Mailing Address - Street 1: | 400 MEMORIAL DRIVE EXT STE 400 |
Mailing Address - Street 2: | |
Mailing Address - City: | GREER |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29651-1850 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 864-282-1935 |
Mailing Address - Fax: | 864-751-6387 |
Practice Address - Street 1: | 12 CLEVELAND CT |
Practice Address - Street 2: | |
Practice Address - City: | GREENVILLE |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29607-2414 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-242-0496 |
Practice Address - Fax: | 864-250-0965 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | FDH HOLDINGS |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2022-05-17 |
Last Update Date: | 2023-01-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |