Provider Demographics
NPI:1336295914
Name:WIX, CRAIG SEWELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:SEWELL
Last Name:WIX
Suffix:
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:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-0846
Mailing Address - Country:US
Mailing Address - Phone:803-259-7645
Mailing Address - Fax:
Practice Address - Street 1:53 IRVING ST
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-1535
Practice Address - Country:US
Practice Address - Phone:803-259-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC74-3244387OtherEIN