MEDICARE: FAMILY DENTAL HEALTH GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1376498709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTAL HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	400 MEMORIAL DRIVE EXT STE 400
Second Line	:
City	:	GREER
State	:	SC
Zip	:	29651-1850
Country	:	US
Telephone Number	:	864-282-1935
Fax Number	:	864-751-6387

Provider Business Practice Location Address
First Line	:	8012 GARNERS FERRY RD STE D
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-5116
Country	:	US
Telephone Number	:	803-783-0694
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF INSURANCE
Name	:	BETH LOUISE ILLSLEY
Credential	:	N/A
Telephone Number	:	864-282-1935

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/05/2026

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