Healthcare Provider Details

I. General information

NPI: 1114140514
Provider Name (Legal Business Name): LAURA G WALLS FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W CHURCH ST
BATESBURG SC
29006-1706
US

IV. Provider business mailing address

533 W CHURCH ST
BATESBURG SC
29006-1706
US

V. Phone/Fax

Practice location:
  • Phone: 803-532-3331
  • Fax: 803-532-3310
Mailing address:
  • Phone: 803-532-3331
  • Fax: 803-532-3310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberSC3590
License Number StateSC

VIII. Authorized Official

Name: DR. LAURA G WALLS
Title or Position: DENTIST OWNER
Credential: DMD
Phone: 803-532-3331