Provider Demographics
NPI:1053036434
Name:SOUTHERN OAK DENTAL GREENVILLE, LLC
Entity type:Organization
Organization Name:SOUTHERN OAK DENTAL GREENVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-558-7155
Mailing Address - Street 1:101 VERDAE BLVD STE 560
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3834
Mailing Address - Country:US
Mailing Address - Phone:864-558-7155
Mailing Address - Fax:864-900-2511
Practice Address - Street 1:101 VERDAE BLVD STE 560
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3834
Practice Address - Country:US
Practice Address - Phone:864-558-7155
Practice Address - Fax:864-900-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental