Provider Demographics
NPI:1124302773
Name:AUSTELLE, WALLY T III (DMD)
Entity type:Individual
Prefix:
First Name:WALLY
Middle Name:T
Last Name:AUSTELLE
Suffix:III
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 1:839 WAPPOO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-556-4746
Mailing Address - Fax:
Practice Address - Street 1:839 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-556-4746
Practice Address - Fax:843-556-5435
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist