Provider Demographics
NPI:1134242621
Name:JEFFREY H WALLEN D.D.S. P.C.
Entity type:Organization
Organization Name:JEFFREY H WALLEN D.D.S. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-449-4993
Mailing Address - Street 1:1200 48TH AVE N STE 101
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5423
Mailing Address - Country:US
Mailing Address - Phone:843-449-4993
Mailing Address - Fax:843-497-0647
Practice Address - Street 1:1200 48TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5423
Practice Address - Country:US
Practice Address - Phone:843-449-4993
Practice Address - Fax:843-497-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998844OtherNORTH CAROLINA MEDICIAD
SCZA9905Medicaid
NC8998844OtherNORTH CAROLINA MEDICIAD
SCU56498Medicare UPIN