Provider Demographics
NPI:1568654275
Name:MARSHLANDS FAMILY DENTISTRY,PA
Entity Type:Organization
Organization Name:MARSHLANDS FAMILY DENTISTRY,PA
Other - Org Name:EDWARD M WISE DMD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GURGANIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-521-4344
Mailing Address - Street 1:1090 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5437
Mailing Address - Country:US
Mailing Address - Phone:843-521-4344
Mailing Address - Fax:843-521-1804
Practice Address - Street 1:1090 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5437
Practice Address - Country:US
Practice Address - Phone:843-521-4344
Practice Address - Fax:843-521-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCZ17771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ17777Medicaid
1302242OtherUCCI
SCZA9852Medicaid
826791OtherUNITED CONCORDIA
SC829922OtherUNITED CONCORDIA