Basic Information
Provider Information | |||||||||
NPI: | 1518336924 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEBEDIAH S. CHRISTY, DDS - MYRTLE BEACH PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3189 | ||||||||
Address2: |   | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132203189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154546000 | ||||||||
FaxNumber: | 3154105531 | ||||||||
Practice Location | |||||||||
Address1: | 1209 N RETAIL CT | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295779626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438744060 | ||||||||
FaxNumber: | 8434436952 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2015 | ||||||||
LastUpdateDate: | 10/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHRISTY | ||||||||
AuthorizedOfficialFirstName: | JEBEDIAH | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3154546000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8613 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.