NPIMap

Organization Active NPI

Sea Glass Periodontics of Greenville

  • Periodontics
  • Greenville, SC
National Provider Identifier
1568084408
Registry record updated Oct 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
Legal business name
SEA GLASS PERIODONTICS OF GREENVILLE
Doing business as
Sea Glass Periodontics of Greenville
Practice address
600 Congaree Rd
Greenville, SC 29607-3518
Phone
(864) 757-8820
Fax
(864) 751-6387
NPI assigned
May 14, 2020
Last updated
Oct 9, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SEA GLASS PERIODONTICS, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 9, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Beth Illsley
Title
Director of Insurance
Phone
(864) 282-1935

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X Primary

Addresses

Primary practice location

600 Congaree Rd
Greenville, SC 29607-3518

Mailing address

400 Memorial Drive Ext Ste 400
Greer, SC 29651-1850
Phone (864) 282-1935

Other names 2

  • Sea Glass Periodontics of Greenville Doing business as
  • Diane Jenkins Periodontics of Congaree LLC Former legal business name

National Provider Directory

National Provider Directory
Part of
Sea Glass Periodontics

Locations

600 Congaree Rd
Greenville, SC 29607
Phone (864) 757-8820

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1589414400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728432000000",
    "number": "1568084408",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 MEMORIAL DRIVE EXT STE 400",
            "city": "GREER",
            "state": "SC",
            "postal_code": "296511850",
            "telephone_number": "864-282-1935",
            "fax_number": "864-751-6387"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 CONGAREE RD",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296073518",
            "telephone_number": "864-757-8820",
            "fax_number": "864-751-6387"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SEA GLASS PERIODONTICS OF GREENVILLE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SEA GLASS PERIODONTICS, LLC",
        "enumeration_date": "2020-05-14",
        "last_updated": "2024-10-09",
        "certification_date": "2024-10-09",
        "status": "A",
        "authorized_official_last_name": "ILLSLEY",
        "authorized_official_first_name": "BETH",
        "authorized_official_title_or_position": "DIRECTOR OF INSURANCE",
        "authorized_official_telephone_number": "864-282-1935",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sea Glass Periodontics of Greenville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Diane Jenkins Periodontics of Congaree LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Diane Jenkins Periodontics of Congaree LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Greenville, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.