Provider Demographics
NPI:1902019722
Name:SOUTHEAST ENDODONTICS, PC
Entity Type:Organization
Organization Name:SOUTHEAST ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-766-0112
Mailing Address - Street 1:10 E FARMFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-766-0112
Mailing Address - Fax:843-766-0884
Practice Address - Street 1:10 FARMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7756
Practice Address - Country:US
Practice Address - Phone:843-766-0112
Practice Address - Fax:843-766-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37071223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty