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General NPI Number Information
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NPI Number | 1639432990
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Entity Type | Organization
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Legal Business Name | EASTSIDE FAMILY DENTAL CARE, LLC
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Dates
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Enumeration Date | 06/21/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 3620 E RIVER ST
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City | ANDERSON
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State | SC
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Zip | 29621-7334
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Country | US
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Telephone | 864-261-3132
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Fax |
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Provider Business Mailing Address
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Address Line | 3620 E RIVER ST
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City | ANDERSON
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State | SC
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Zip | 29621-7334
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Country | US
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Telephone | 864-261-3132
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | JOHN WESLEY HARDEN
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Credential | DMD
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Telephone | 864-246-1811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7141
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4272
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License Number State | SC
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