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General NPI Number Information
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NPI Number | 1659561439
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Entity Type | Organization
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Legal Business Name | HONEA PATH FAMILY DENTISTRY, PA
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Dates
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Enumeration Date | 07/27/2007
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Last Update Date | 03/15/2013
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Provider Practice Location Address
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Address Line | 322 N SHIRLEY AVE
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City | HONEA PATH
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State | SC
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Zip | 29654-1636
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Country | US
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Telephone | 864-369-2966
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Fax | 864-369-0666
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Provider Business Mailing Address
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Address Line | 322 N SHIRLEY AVE
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City | HONEA PATH
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State | SC
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Zip | 29654-1636
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Country | US
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Telephone | 864-369-2966
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Fax | 864-369-0666
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SHANNON B. WILSON
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Credential | DMD
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Telephone | 864-369-2966
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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 | 3886
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License Number State | SC
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