Provider Demographics
NPI:1316216500
Name:SURFSIDE DENTAL LLC
Entity Type:Organization
Organization Name:SURFSIDE DENTAL LLC
Other - Org Name:SURFSIDE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-652-0011
Mailing Address - Street 1:11919 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9356
Mailing Address - Country:US
Mailing Address - Phone:843-652-0011
Mailing Address - Fax:888-636-7841
Practice Address - Street 1:1665 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4836
Practice Address - Country:US
Practice Address - Phone:843-215-6080
Practice Address - Fax:888-636-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty