Healthcare Provider Details

I. General information

NPI: 1104202662
Provider Name (Legal Business Name): US NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

IV. Provider business mailing address

7034 W AIRE LIBRE AVE
PEORIA AZ
85382-3963
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-5994
  • Fax: 843-228-5728
Mailing address:
  • Phone: 626-321-2334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberDGD,8626.GD
License Number StateSC

VIII. Authorized Official

Name: DR. GEORGE LEIGH WALRATH
Title or Position: DENTIST
Credential: DMD
Phone: 626-321-2334