Healthcare Provider Details

I. General information

NPI: 1417309451
Provider Name (Legal Business Name): ASHBY PARK PEDIATRIC DENTISTRY EASLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 NORTH A STREET
EASLEY SC
29640
US

IV. Provider business mailing address

708 NORTH A STREET
EASLEY SC
29640
US

V. Phone/Fax

Practice location:
  • Phone: 864-605-7741
  • Fax:
Mailing address:
  • Phone: 864-605-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3638
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3638
License Number StateSC

VIII. Authorized Official

Name: JENNIFER GARVEY
Title or Position: PARTNER/OWNER
Credential:
Phone: 864-234-3424