Provider Demographics
NPI:1639245772
Name:TALBERT, THOMAS WILLIAM JR (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:TALBERT
Suffix:JR
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 1:1707 BERNARDIN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2004
Mailing Address - Country:US
Mailing Address - Phone:803-254-5764
Mailing Address - Fax:
Practice Address - Street 1:1707 BERNARDIN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2004
Practice Address - Country:US
Practice Address - Phone:803-254-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ2001-3Medicaid
SC30-02001OtherSTATE DEA REGISTRATION
AT7080930OtherDEA REGISTRATION