Healthcare Provider Details

I. General information

NPI: 1821708595
Provider Name (Legal Business Name): SEABREEZE ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SURGEONS DR
MYRTLE BEACH SC
29579-5198
US

IV. Provider business mailing address

107 SURGEONS DR
MYRTLE BEACH SC
29579-5198
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-3300
  • Fax:
Mailing address:
  • Phone: 843-903-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JUAN FAJA FERNANDEZ
Title or Position: ORTHODONTIST/BUSINESS OWNER
Credential: DMD
Phone: 843-903-3300