Provider Demographics
NPI:1851115810
Name:SURFSIDE SW LLC
Entity type:Organization
Organization Name:SURFSIDE SW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-450-1886
Mailing Address - Street 1:11919 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9356
Mailing Address - Country:US
Mailing Address - Phone:843-450-1886
Mailing Address - Fax:
Practice Address - Street 1:811 5TH AVE N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-3967
Practice Address - Country:US
Practice Address - Phone:843-450-1886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty