Provider Demographics
NPI:1497729396
Name:WALLEN, JEFFREY H (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:H
Last Name:WALLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 48TH AVE N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5425
Mailing Address - Country:US
Mailing Address - Phone:843-449-4993
Mailing Address - Fax:843-497-0647
Practice Address - Street 1:1200 48TH AVE N
Practice Address - Street 2:SUITE 101
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5425
Practice Address - Country:US
Practice Address - Phone:843-449-4993
Practice Address - Fax:843-497-0647
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2959204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9905Medicaid
NC8998844Medicaid
SCZA9905Medicaid