Healthcare Provider Details

I. General information

NPI: 1255882908
Provider Name (Legal Business Name): SOUTH CAROLINA DENTAL SLEEP CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 GARLINGTON RD STE 200
GREENVILLE SC
29615-4629
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-207-7141
  • Fax:
Mailing address:
  • Phone: 864-282-1935
  • Fax: 864-751-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

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