Provider Demographics
NPI:1790971927
Name:GRAND STRAND FAMILY AND ESTHETIC DENTISTRY
Entity Type:Organization
Organization Name:GRAND STRAND FAMILY AND ESTHETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-293-6606
Mailing Address - Street 1:4884 SOCASTEE BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7245
Mailing Address - Country:US
Mailing Address - Phone:843-293-6606
Mailing Address - Fax:
Practice Address - Street 1:4884 SOCASTEE BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7245
Practice Address - Country:US
Practice Address - Phone:843-293-6606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND STRAND FAMILY AND ESTHETIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-20
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9570Medicaid