Provider Demographics
NPI:1780184036
Name:MARSHLANDS II FAMILY DENTISTRY, PA
Entity Type:Organization
Organization Name:MARSHLANDS II FAMILY DENTISTRY, PA
Other - Org Name:MARSHLANDS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN DAVID
Authorized Official - Middle Name:SOUTHERLAND
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
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:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4601261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4601Medicaid
SC1134233935OtherNPI
SC1548499635OtherNPI
SCZ17777Medicaid