Healthcare Provider Details

I. General information

NPI: 1720803976
Provider Name (Legal Business Name): FAMILY DENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 WASHINGTON RD
AUGUSTA GA
30904-3105
US

IV. Provider business mailing address

400 MEMORIAL DRIVE EXT STE 400
GREER SC
29651-1850
US

V. Phone/Fax

Practice location:
  • Phone: 706-736-7146
  • Fax:
Mailing address:
  • Phone: 864-282-1935
  • Fax: 864-751-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETH LOUISE ILLSLEY
Title or Position: DIRECTOR OF INSURANCE
Credential:
Phone: 864-282-1935