Provider Demographics
NPI:1568420933
Name:MCELVEEN JR., JESSE WOODROW (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WOODROW
Last Name:MCELVEEN JR.
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29484-1247
Mailing Address - Country:US
Mailing Address - Phone:843-871-0433
Mailing Address - Fax:843-871-0433
Practice Address - Street 1:2039 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7821
Practice Address - Country:US
Practice Address - Phone:843-871-0433
Practice Address - Fax:843-871-0433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ20460Medicaid
RI157210OtherBETTER HEALTH PLAN ID#
SCZA9943Medicaid
SC488858OtherUNITED CONCORDIA ID#
SCZA035 3OtherBCBS SC ID#