Provider Demographics
NPI:1013988344
Name:TEAL, EDWARD WESLEY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WESLEY
Last Name:TEAL
Suffix:JR
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 1:4004 BAYBORO STREET
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569
Mailing Address - Country:US
Mailing Address - Phone:843-756-2273
Mailing Address - Fax:843-756-0242
Practice Address - Street 1:4004 BAYBORO ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2867
Practice Address - Country:US
Practice Address - Phone:843-756-2273
Practice Address - Fax:843-756-0242
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ28346Medicaid