Provider Demographics
NPI:1598142341
Name:SUNSET PERIODONTICS, LLC
Entity Type:Organization
Organization Name:SUNSET PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MHS
Authorized Official - Phone:317-345-3113
Mailing Address - Street 1:159 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3655
Mailing Address - Country:US
Mailing Address - Phone:803-794-7520
Mailing Address - Fax:
Practice Address - Street 1:159 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-794-7520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8261223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty