Healthcare Provider Details

I. General information

NPI: 1982920617
Provider Name (Legal Business Name): FAMILY DENTAL HEALTH OF BLUE RIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2543 LOCUST HILL RD
TAYLORS SC
29687-5835
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 864-879-9898
  • Fax: 864-879-9895
Mailing address:
  • Phone: 864-282-1935
  • Fax: 864-751-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4138
License Number StateSC

VIII. Authorized Official

Name: MRS. BETH ILLSLEY
Title or Position: INSURANCE DIRECTOR
Credential:
Phone: 864-282-1935