MEDICARE: GRAND STRAND FAMILY AND ESTHETIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2503	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790971927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND STRAND FAMILY AND ESTHETIC DENTISTRY

Provider Business Mailing Address
First Line	:	4884 SOCASTEE BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7245
Country	:	US
Telephone Number	:	843-293-6606
Fax Number	:

Provider Business Practice Location Address
First Line	:	4884 SOCASTEE BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7245
Country	:	US
Telephone Number	:	843-293-6606
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	DR. WALTER J MACHOWSKI
Credential	:	DMD
Telephone Number	:	843-293-6606

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	01/28/2008

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Directions to “GRAND STRAND FAMILY AND ESTHETIC DENTISTRY ” Practice Location

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