Provider Demographics
NPI:1831700178
Name:FLEETWOOD SQUARE DENTAL, LLC
Entity type:Organization
Organization Name:FLEETWOOD SQUARE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-855-2788
Mailing Address - Street 1:105 FLEETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2019
Mailing Address - Country:US
Mailing Address - Phone:864-855-2788
Mailing Address - Fax:864-855-2789
Practice Address - Street 1:105 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2019
Practice Address - Country:US
Practice Address - Phone:864-855-2788
Practice Address - Fax:864-855-2689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental