MEDICARE: EASTSIDE FAMILY DENTISTRY PA

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	2891	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548363591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE FAMILY DENTISTRY PA

Provider Business Mailing Address
First Line	:	3620 EAST RIVER ST
Second Line	:
City	:	ANDERSON
State	:	SC
Zip	:	29621-7334
Country	:	US
Telephone Number	:	864-261-3132
Fax Number	:	864-261-6614

Provider Business Practice Location Address
First Line	:	3620 EAST RIVER ST
Second Line	:
City	:	ANDERSON
State	:	SC
Zip	:	29621-7334
Country	:	US
Telephone Number	:	864-261-3132
Fax Number	:	864-261-6614

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STANLEY WARING SHEFTALL JR.
Credential	:	DMD
Telephone Number	:	864-261-3132

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/27/2008

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Directions to “EASTSIDE FAMILY DENTISTRY PA ” Practice Location

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