Provider Demographics
NPI:1629125562
Name:WIMER, JONATHAN POLK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:POLK
Last Name:WIMER
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 1:1815 OLD TROLLEY RD
Mailing Address - Street 2:SUITE107
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8284
Mailing Address - Country:US
Mailing Address - Phone:843-832-4560
Mailing Address - Fax:843-832-4214
Practice Address - Street 1:176 TYVOLA DRIVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485
Practice Address - Country:US
Practice Address - Phone:843-832-4560
Practice Address - Fax:843-832-4214
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC40011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice