Provider Demographics
NPI:1538457387
Name:DWC-J, LLC
Entity Type:Organization
Organization Name:DWC-J, LLC
Other - Org Name:DENTAL WELLNESS CENTER OF JESUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:TROUT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-665-2792
Mailing Address - Street 1:135 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0211
Mailing Address - Country:US
Mailing Address - Phone:912-665-2792
Mailing Address - Fax:888-289-4301
Practice Address - Street 1:135 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0211
Practice Address - Country:US
Practice Address - Phone:912-665-2792
Practice Address - Fax:888-289-4301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHTDMD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 10747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty