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General NPI Number Information
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NPI Number | 1821526294
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Entity Type | Organization
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Legal Business Name | SUNNYSIDE FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 05/30/2017
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Last Update Date | 05/30/2017
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Provider Practice Location Address
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Address Line | 1500 W MAIN ST UNIT 110
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City | LAURENS
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State | SC
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Zip | 29360-3767
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Country | US
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Telephone | 864-715-2227
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Fax |
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Provider Business Mailing Address
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Address Line | 119 YOUNG HARRIS DR
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City | SIMPSONVILLE
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State | SC
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Zip | 29681-8115
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CHIKA AGU
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Credential | DDS
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Telephone | 864-715-2227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 7101
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License Number State | SC
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