Provider Demographics
NPI:1902521396
Name:SOUTHERN OAK DENTAL CONWAY, LLC
Entity Type:Organization
Organization Name:SOUTHERN OAK DENTAL CONWAY, 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 1:2676 CHURCH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4471
Mailing Address - Country:US
Mailing Address - Phone:843-733-3387
Mailing Address - Fax:843-428-0070
Practice Address - Street 1:2676 CHURCH ST UNIT A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4471
Practice Address - Country:US
Practice Address - Phone:843-733-3387
Practice Address - Fax:843-428-0070
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