Healthcare Provider Details

I. General information

NPI: 1689520140
Provider Name (Legal Business Name): PENDLETON NEIGHBORHOOD DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2026
Last Update Date: 03/07/2026
Certification Date: 03/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 COTESWORTH ST UNIT E
PENDLETON SC
29670-9545
US

IV. Provider business mailing address

137 COTESWORTH ST UNIT E
PENDLETON SC
29670-9545
US

V. Phone/Fax

Practice location:
  • Phone: 714-423-4436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KERILLS HOSSAM AZER HABASHI
Title or Position: DENTIST
Credential: DMD
Phone: 714-423-4436