1194181297 NPI number — HOLLY TREE FAMILY DENTAL

Table of content: (NPI 1194181297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194181297 NPI number — HOLLY TREE FAMILY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLY TREE FAMILY DENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194181297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1673 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29640-3791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-442-6770
Provider Business Mailing Address Fax Number:
864-442-6830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1673 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASLEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29640-3791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-442-6770
Provider Business Practice Location Address Fax Number:
864-442-6830
Provider Enumeration Date:
01/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BYNUM
Authorized Official First Name:
ANN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
864-442-6770

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  3427 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZA9157 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com