Provider Demographics
NPI:1922312115
Name:FAMILY DENTAL HEALTH OF VILLA ROAD, LLC
Entity Type:Organization
Organization Name:FAMILY DENTAL HEALTH OF VILLA ROAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:MONROE
Authorized Official - Last Name:SAFRIT
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
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 1:110 VILLA RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3010
Practice Address - Country:US
Practice Address - Phone:864-282-1925
Practice Address - Fax:864-282-1913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FDH HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-30
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty