Provider Demographics
NPI:1821526294
Name:SUNNYSIDE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SUNNYSIDE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-715-2227
Mailing Address - Street 1:119 YOUNG HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-8115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 W MAIN ST UNIT 110
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-3767
Practice Address - Country:US
Practice Address - Phone:864-715-2227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7101261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental