=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841263845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE PEDIATRIC DENTISTRY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 10/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 POINTE CIR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-233-1234
-----------------------------------------------------
Fax | 864-298-8009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 POINTE CIR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-233-1234
-----------------------------------------------------
Fax | 864-298-8009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GLENN ROBERT HEAD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 864-233-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2868
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------