Provider Demographics
NPI:1295453751
Name:ISSAQUEENA PEDIATRIC DENTISTRY P.A.
Entity type:Organization
Organization Name:ISSAQUEENA PEDIATRIC DENTISTRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:WORTHINGTON
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-482-7900
Mailing Address - Street 1:314 UNION STATION DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-4547
Mailing Address - Country:US
Mailing Address - Phone:864-482-7900
Mailing Address - Fax:864-482-7510
Practice Address - Street 1:3453 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-7725
Practice Address - Country:US
Practice Address - Phone:864-625-1283
Practice Address - Fax:864-565-7784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISSAQUEENA PEDIATRIC DENTISTRY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty