Healthcare Provider Details

I. General information

NPI: 1538457387
Provider Name (Legal Business Name): DWC-J, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PEACHTREE ST
JESUP GA
31545-0211
US

IV. Provider business mailing address

135 PEACHTREE ST
JESUP GA
31545-0211
US

V. Phone/Fax

Practice location:
  • Phone: 912-665-2792
  • Fax: 888-289-4301
Mailing address:
  • Phone: 912-665-2792
  • Fax: 888-289-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberGA 10747
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM HOWARD TROUT JR.
Title or Position: MANAGING PARTNER
Credential: DMD
Phone: 912-665-2792