Healthcare Provider Details

I. General information

NPI: 1609086149
Provider Name (Legal Business Name): CEDAR BLUFF FAMILY AND COSMETIC DENTISTRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 B FAIRVIEW RD SUITE 1
SIMPSONVILLE SC
29860
US

IV. Provider business mailing address

634B FAIRVIEW RD STE 1
SIMPSONVILLE SC
29680-6700
US

V. Phone/Fax

Practice location:
  • Phone: 864-962-6787
  • Fax:
Mailing address:
  • Phone: 864-962-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEREMY R BAYER
Title or Position: PRESIDENT
Credential:
Phone: 864-962-6787