Provider Demographics
NPI:1457666471
Name:CAROLINA PERIODONTICS & ENDODONTICS LLC
Entity Type:Organization
Organization Name:CAROLINA PERIODONTICS & ENDODONTICS LLC
Other - Org Name:PALMETTO DENTAL SPECIALISTS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PERIODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-579-0026
Mailing Address - Street 1:1033 BAYSHORE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1569
Mailing Address - Country:US
Mailing Address - Phone:803-327-4444
Mailing Address - Fax:803-327-4443
Practice Address - Street 1:1033 BAYSHORE DR
Practice Address - Street 2:SUITE A
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1569
Practice Address - Country:US
Practice Address - Phone:803-327-4444
Practice Address - Fax:803-327-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDENTAL: 46581223E0200X
SCDENTAL: 46671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty