Healthcare Provider Details

I. General information

NPI: 1417194853
Provider Name (Legal Business Name): GENTLE DENTAL CARE OF BLACKSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W PINE ST
BLACKSBURG SC
29702-1549
US

IV. Provider business mailing address

305 W PINE ST
BLACKSBURG SC
29702-1549
US

V. Phone/Fax

Practice location:
  • Phone: 864-839-0034
  • Fax:
Mailing address:
  • Phone: 864-839-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3241
License Number StateSC

VIII. Authorized Official

Name: DR. KEVIN L WILLIAMS
Title or Position: PRESIDENT
Credential: DMD
Phone: 864-839-0034