| NPI | 1134242621 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEFFREY HUGH WALLEN Owner 843-449-4993 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SC 2959) |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2008-06-05 |