Healthcare Provider Details

I. General information

NPI: 1942113808
Provider Name (Legal Business Name): SPARK ORTHODONTICS SC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 FARRS BRIDGE RD
GREENVILLE SC
29617-1858
US

IV. Provider business mailing address

PO BOX 831228
PHILADELPHIA PA
19182-1228
US

V. Phone/Fax

Practice location:
  • Phone: 864-232-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHERRIE EDMONDSON
Title or Position: DIRECTOR
Credential:
Phone: 629-666-8621