Provider Demographics
NPI:1023122793
Name:BLUE RIDGE ENDODONTICS, L.L.C.
Entity type:Organization
Organization Name:BLUE RIDGE ENDODONTICS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CARVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:865-654-1715
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-0312
Mailing Address - Country:US
Mailing Address - Phone:864-654-1715
Mailing Address - Fax:864-654-1730
Practice Address - Street 1:101 FINLEY ST STE A
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1583
Practice Address - Country:US
Practice Address - Phone:864-654-1715
Practice Address - Fax:864-654-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty