Healthcare Provider Details

I. General information

NPI: 1497729396
Provider Name (Legal Business Name): JEFFREY H WALLEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 48TH AVE N SUITE 101
MYRTLE BEACH SC
29577-5425
US

IV. Provider business mailing address

1200 48TH AVE N SUITE 101
MYRTLE BEACH SC
29577-5425
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-4993
  • Fax: 843-497-0647
Mailing address:
  • Phone: 843-449-4993
  • Fax: 843-497-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2959
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: