=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548363591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE FAMILY DENTISTRY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 08/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 EAST RIVER ST
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29621-7334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-261-3132
-----------------------------------------------------
Fax | 864-261-6614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3620 EAST RIVER ST
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29621-7334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-261-3132
-----------------------------------------------------
Fax | 864-261-6614
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STANLEY WARING SHEFTALL JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 864-261-3132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2891
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------