Provider Demographics
NPI:1770755399
Name:HEALTHY SMILES OF SPARTANBURG
Entity type:Organization
Organization Name:HEALTHY SMILES OF SPARTANBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RODDEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-592-4698
Mailing Address - Street 1:PO BOX 1441
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-1441
Mailing Address - Country:US
Mailing Address - Phone:864-592-4698
Mailing Address - Fax:864-592-4697
Practice Address - Street 1:800 BRISACK ROAD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-592-4698
Practice Address - Fax:864-592-4697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCW01524SC1Medicaid