Provider Demographics
NPI:1831931021
Name:BIG WAVES ENDODONTICS
Entity type:Organization
Organization Name:BIG WAVES ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:PORRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-492-7979
Mailing Address - Street 1:584 STARLIT WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4603 OLEANDER DR STE 6
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5738
Practice Address - Country:US
Practice Address - Phone:843-492-7979
Practice Address - Fax:843-492-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty