MEDICARE: BIG WAVES ENDODONTICS

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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1831931021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG WAVES ENDODONTICS

Provider Business Mailing Address
First Line	:	584 STARLIT WAY
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4322
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4603 OLEANDER DR STE 6
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5738
Country	:	US
Telephone Number	:	843-492-7979
Fax Number	:	843-492-7448

Authorized Official
Title or Position	:	ENDODONTIST
Name	:	DR. BENJAMIN ERIC PORRAS
Credential	:	DMD
Telephone Number	:	843-492-7979

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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