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General NPI Number Information
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NPI Number | 1780184036
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Entity Type | Organization
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Legal Business Name | MARSHLANDS II FAMILY DENTISTRY, PA
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Dates
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Enumeration Date | 02/13/2018
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Last Update Date | 02/13/2018
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Provider Practice Location Address
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Address Line | 1090 RIBAUT RD
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City | BEAUFORT
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State | SC
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Zip | 29902-5437
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Country | US
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Telephone | 843-521-4344
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Fax | 843-521-1804
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Provider Business Mailing Address
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Address Line | 1090 RIBAUT RD
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City | BEAUFORT
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State | SC
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Zip | 29902-5437
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Country | US
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Telephone | 843-521-4344
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Fax | 843-521-1804
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. JOHN DAVID SOUTHERLAND WISE
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Credential | DMD
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Telephone | 843-521-4344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4601
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License Number State | SC
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