Provider Demographics
NPI:1902458474
Name:CLASSIC DENTAL GROUP
Entity type:Organization
Organization Name:CLASSIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:TYRESIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-283-0141
Mailing Address - Street 1:6A CLEVELAND CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2414
Mailing Address - Country:US
Mailing Address - Phone:864-283-0141
Mailing Address - Fax:
Practice Address - Street 1:6A 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:864-283-0141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty