MEDICARE: EASTSIDE FAMILY DENTAL CARE, 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	122300000X	Dentist	7141	SC
2	122300000X	Dentist	4272	SC

General Provider Information

NPI Number	:	1639432990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE FAMILY DENTAL CARE, LLC

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

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

Authorized Official
Title or Position	:	DENTIST
Name	:	JOHN WESLEY HARDEN
Credential	:	DMD
Telephone Number	:	864-246-1811

Provider Enumeration Date	:	06/21/2012
Last Update Date	:	06/21/2012

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