Provider Demographics
NPI:1336326727
Name:ISENHOWER, CRYSTAL H (DMD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:H
Last Name:ISENHOWER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WACCAMAW MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8902
Mailing Address - Country:US
Mailing Address - Phone:843-234-3110
Mailing Address - Fax:843-234-3109
Practice Address - Street 1:107 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8902
Practice Address - Country:US
Practice Address - Phone:843-234-3110
Practice Address - Fax:843-234-3109
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9675Medicaid