Healthcare Provider Details

I. General information

NPI: 1366522922
Provider Name (Legal Business Name): GREENVILLE PEDIATRIC DENTISTRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1376 CLEVELAND ST
GREENVILLE SC
29607-2435
US

IV. Provider business mailing address

1376 CLEVELAND ST
GREENVILLE SC
29607-2435
US

V. Phone/Fax

Practice location:
  • Phone: 864-250-1100
  • Fax: 864-250-1604
Mailing address:
  • Phone: 864-250-1100
  • Fax: 864-250-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY KNIGHT PORTER
Title or Position: INSURANCE CLAIMS MANAGER
Credential:
Phone: 864-250-1100