Provider Demographics
NPI:1588629638
Name:PRICKETT, PHILIP M (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:PRICKETT
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 1:1755 ST. JULIAN PLACE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-254-2972
Mailing Address - Fax:803-799-2151
Practice Address - Street 1:1755 ST. JULIAN PLACE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-254-2972
Practice Address - Fax:803-799-2151
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3132204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA31323Medicaid
SCU554128290Medicare ID - Type Unspecified
SCU55412Medicare UPIN