MEDICARE: SEA GLASS PERIODONTICS OF GREENVILLE

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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1568084408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA GLASS PERIODONTICS OF GREENVILLE

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	:	600 CONGAREE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-3518
Country	:	US
Telephone Number	:	864-757-8820
Fax Number	:	864-751-6387

Authorized Official
Title or Position	:	DIRECTOR OF INSURANCE
Name	:	MRS. BETH ILLSLEY
Credential	:
Telephone Number	:	864-282-1935

Provider Enumeration Date	:	05/14/2020
Last Update Date	:	10/09/2024

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