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	:	1679443717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTAL HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	400 MEMORIAL DRIVE EXT
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	:	5 LAKE CAROLINA WAY STE 210
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-7563
Country	:	US
Telephone Number	:	803-736-8606
Fax Number	:

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

Provider Enumeration Date	:	11/05/2025
Last Update Date	:	11/05/2025

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