Provider Demographics
NPI:1598856353
Name:SOUTH CAROLINA PERIODONTOLOGY PA
Entity Type:Organization
Organization Name:SOUTH CAROLINA PERIODONTOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLEVELAND
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-782-0528
Mailing Address - Street 1:2120 N BELTLINE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-3905
Mailing Address - Country:US
Mailing Address - Phone:803-782-0528
Mailing Address - Fax:803-782-1036
Practice Address - Street 1:2120 N BELTLINE BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-3905
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:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty