Provider Demographics
NPI:1912196684
Name:PALMETTO FAMILY ORTHODONTICS LLC
Entity Type:Organization
Organization Name:PALMETTO FAMILY ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD MPH
Authorized Official - Phone:864-335-0505
Mailing Address - Street 1:105 HALTON VILLAGE CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6833
Mailing Address - Country:US
Mailing Address - Phone:864-335-0505
Mailing Address - Fax:864-335-0508
Practice Address - Street 1:105 HALTON VILLAGE CIR
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6833
Practice Address - Country:US
Practice Address - Phone:864-335-0505
Practice Address - Fax:864-335-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6811223X0400X
SC42871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty