Provider Demographics
NPI:1831356021
Name:SOUTHERN OAKS FAMILY DENTISTRY, PA
Entity type:Organization
Organization Name:SOUTHERN OAKS FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-850-9100
Mailing Address - Street 1:3904 HIGHWAY 86
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-9549
Mailing Address - Country:US
Mailing Address - Phone:864-850-9100
Mailing Address - Fax:864-850-0250
Practice Address - Street 1:3904 HIGHWAY 86
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-9549
Practice Address - Country:US
Practice Address - Phone:864-850-9100
Practice Address - Fax:864-850-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty