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General NPI Number Information
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NPI Number | 1629184171
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Entity Type | Organization
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Legal Business Name | CRYSTAL ISENHOWER, DMD, LLC
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 107 WACCAMAW MEDICAL PARK DR
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City | CONWAY
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State | SC
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Zip | 29526-8902
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Country | US
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Telephone | 843-234-3110
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Fax | 843-234-3109
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Provider Business Mailing Address
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Address Line | 107 WACCAMAW MEDICAL PARK DR
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City | CONWAY
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State | SC
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Zip | 29526-8902
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Country | US
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Telephone | 843-234-3110
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Fax | 843-234-3109
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Authorized Official
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Title or Position | DENTIST
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Name | DR. CRYSTAL RAE ISENHOWER
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Credential | DMD
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Telephone | 843-234-3110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3529
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License Number State | SC
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