Provider Demographics
NPI:1942226386
Name:DILLON FAMILY DENTAL CENTER PC
Entity Type:Organization
Organization Name:DILLON FAMILY DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:FINCANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-774-7662
Mailing Address - Street 1:101 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2421
Mailing Address - Country:US
Mailing Address - Phone:843-774-7662
Mailing Address - Fax:843-774-7920
Practice Address - Street 1:101 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2421
Practice Address - Country:US
Practice Address - Phone:843-774-7662
Practice Address - Fax:843-774-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9907Medicaid
NC89088XMedicaid