Provider Demographics
NPI:1093096984
Name:ADULT AND CHILDREN'S DENTISTRY AT CAROLINA FOREST INC
Entity Type:Organization
Organization Name:ADULT AND CHILDREN'S DENTISTRY AT CAROLINA FOREST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-457-4651
Mailing Address - Street 1:4032 RIVER OAKS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6696
Mailing Address - Country:US
Mailing Address - Phone:843-903-8800
Mailing Address - Fax:
Practice Address - Street 1:4032 RIVER OAKS DR STE 2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6696
Practice Address - Country:US
Practice Address - Phone:843-903-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3446122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty