Provider Demographics
NPI:1891286613
Name:TYLAN CREEK FAMILY DENTISTRY GREENWOOD
Entity Type:Organization
Organization Name:TYLAN CREEK FAMILY DENTISTRY GREENWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:HALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-407-4455
Mailing Address - Street 1:330 HARRISON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7133
Mailing Address - Country:US
Mailing Address - Phone:864-630-9103
Mailing Address - Fax:864-962-6683
Practice Address - Street 1:3710 HIGHWAY 221- 72E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649
Practice Address - Country:US
Practice Address - Phone:864-630-9103
Practice Address - Fax:864-603-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2867261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2867OtherDENTAL LICENSE