Provider Demographics
NPI:1578009056
Name:SOUTHERN ROOTS PERIODONTICS: IMPLANT & LASER DENTISTRY, LLC
Entity Type:Organization
Organization Name:SOUTHERN ROOTS PERIODONTICS: IMPLANT & LASER DENTISTRY, LLC
Other - Org Name:SOUTH CAROLINA PERIODONTOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:803-782-0528
Mailing Address - Street 1:2120 N BELTLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4518
Mailing Address - Country:US
Mailing Address - Phone:803-782-0528
Mailing Address - Fax:803-782-1036
Practice Address - Street 1:2120 N BELTLINE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4518
Practice Address - Country:US
Practice Address - Phone:803-782-0528
Practice Address - Fax:803-782-1036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8489261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental