Provider Demographics
NPI:1912125782
Name:NORTHEAST FAMILY DENTISTRY
Entity Type:Organization
Organization Name:NORTHEAST FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:REID
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD RN
Authorized Official - Phone:803-865-2602
Mailing Address - Street 1:7711 TRENHOLM ROAD EXTENSION
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1725
Mailing Address - Country:US
Mailing Address - Phone:803-865-2602
Mailing Address - Fax:803-865-1814
Practice Address - Street 1:7711 TRENHOLM ROAD EXTENSION
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1725
Practice Address - Country:US
Practice Address - Phone:803-865-2602
Practice Address - Fax:803-865-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA 9746Medicaid