Provider Demographics
NPI:1689647307
Name:WITHERSPOON, WALTER PENNINGTON JR (DDS MSO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:PENNINGTON
Last Name:WITHERSPOON
Suffix:JR
Gender:M
Credentials:DDS MSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3653
Mailing Address - Country:US
Mailing Address - Phone:803-796-5300
Mailing Address - Fax:803-796-5301
Practice Address - Street 1:205 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3653
Practice Address - Country:US
Practice Address - Phone:803-796-5300
Practice Address - Fax:803-796-5301
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1304122300000X, 1223X0400X
SC94122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC213041OtherDEPT OF HLTH & HUMAN SVS