Provider Demographics
NPI:1972879682
Name:VAN WIE, PATTY R (DMD)
Entity type:Individual
Prefix:DR
First Name:PATTY
Middle Name:R
Last Name:VAN WIE
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:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0635
Mailing Address - Country:US
Mailing Address - Phone:843-249-4092
Mailing Address - Fax:843-249-1638
Practice Address - Street 1:1247 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9211
Practice Address - Country:US
Practice Address - Phone:843-249-4092
Practice Address - Fax:843-249-1638
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice