Provider Demographics
NPI:1720127442
Name:BEREA COMPREHENSIVE DENTISTRY
Entity Type:Organization
Organization Name:BEREA COMPREHENSIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:HARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-246-1811
Mailing Address - Street 1:1906 CEDAR LANE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-1733
Mailing Address - Country:US
Mailing Address - Phone:864-246-1811
Mailing Address - Fax:
Practice Address - Street 1:1906 CEDAR LANE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-1733
Practice Address - Country:US
Practice Address - Phone:864-246-1811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty