Provider Demographics
NPI:1407101918
Name:PALMETTO SURGICAL CONSULTANTS ASSOCIATION,INC.
Entity Type:Organization
Organization Name:PALMETTO SURGICAL CONSULTANTS ASSOCIATION,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACE
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-256-4304
Mailing Address - Street 1:1330 GREGG ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3526
Mailing Address - Country:US
Mailing Address - Phone:803-256-4304
Mailing Address - Fax:
Practice Address - Street 1:1330 GREGG ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3526
Practice Address - Country:US
Practice Address - Phone:803-256-4304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty