Provider Demographics
NPI:1962033001
Name:IVY CREEK FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:IVY CREEK FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERMAINE
Authorized Official - Middle Name:LATRICE
Authorized Official - Last Name:LYDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-302-4445
Mailing Address - Street 1:337 OAKPOINTE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7232
Mailing Address - Country:US
Mailing Address - Phone:912-695-8540
Mailing Address - Fax:
Practice Address - Street 1:9007 TWO NOTCH RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5834
Practice Address - Country:US
Practice Address - Phone:803-302-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty