Provider Demographics
NPI:1790422137
Name:FAMILY DENTAL HEALTH OF CREEKSIDE LLC
Entity type:Organization
Organization Name:FAMILY DENTAL HEALTH OF CREEKSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ILLSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-282-1935
Mailing Address - Street 1:400 MEMORIAL DRIVE EXT STE 400
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1850
Mailing Address - Country:US
Mailing Address - Phone:864-282-1935
Mailing Address - Fax:864-751-6387
Practice Address - Street 1:12 CLEVELAND CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2414
Practice Address - Country:US
Practice Address - Phone:864-242-0496
Practice Address - Fax:864-250-0965
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FDH HOLDINGS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-17
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty