Provider Demographics
NPI:1821708595
Name:SEABREEZE ORTHODONTICS
Entity Type:Organization
Organization Name:SEABREEZE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJA FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-903-3300
Mailing Address - Street 1:107 SURGEONS DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5198
Mailing Address - Country:US
Mailing Address - Phone:843-903-3300
Mailing Address - Fax:
Practice Address - Street 1:107 SURGEONS DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5198
Practice Address - Country:US
Practice Address - Phone:843-903-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty