Provider Demographics
NPI:1558470450
Name:MYRTLE BEACH DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:MYRTLE BEACH DENTAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-449-4372
Mailing Address - Street 1:8151 ROURK ST 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:843-449-4372
Mailing Address - Fax:843-497-9853
Practice Address - Street 1:8151 ROURK ST 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-449-4372
Practice Address - Fax:843-497-9853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29951223G0001X
SC37711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9684Medicaid