Provider Demographics
NPI:1104166792
Name:DUTCH FORK FAMILY DENTISTRY, PA
Entity type:Organization
Organization Name:DUTCH FORK FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:BENENHALEY
Authorized Official - Last Name:RAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-749-3333
Mailing Address - Street 1:7436 BROAD RIVER RD STE 111
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7601
Mailing Address - Country:US
Mailing Address - Phone:803-749-3333
Mailing Address - Fax:803-749-3335
Practice Address - Street 1:7436 BROAD RIVER RD STE 111
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7601
Practice Address - Country:US
Practice Address - Phone:803-749-3333
Practice Address - Fax:803-749-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4654261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental