Provider Demographics
NPI:1962585604
Name:WITKIN, PHILIP SPENCER (DMD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:SPENCER
Last Name:WITKIN
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 1:415 ROBERTSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5713
Mailing Address - Country:US
Mailing Address - Phone:843-549-2121
Mailing Address - Fax:843-549-7705
Practice Address - Street 1:415 ROBERTSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5713
Practice Address - Country:US
Practice Address - Phone:843-549-2121
Practice Address - Fax:843-549-7705
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC993784Medicaid