Healthcare Provider Details

I. General information

NPI: 1902019722
Provider Name (Legal Business Name): SOUTHEAST ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FARMFIELD AVE
CHARLESTON SC
29407-7756
US

IV. Provider business mailing address

10 E FARMFIELD AVENUE
CHARLESTON SC
29407
US

V. Phone/Fax

Practice location:
  • Phone: 843-766-0112
  • Fax: 843-766-0884
Mailing address:
  • Phone: 843-766-0112
  • Fax: 843-766-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3707
License Number StateSC

VIII. Authorized Official

Name: DR. WALTER R. LONG
Title or Position: OWNER
Credential: D.M.D.
Phone: 843-766-0112