MEDICARE: DR. EDGAR HAROLD PEACOCK JR. D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	1545	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275536245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDGAR HAROLD PEACOCK JR. D.D.S.

Provider Business Mailing Address
First Line	:	2750 LAUREL ST
Second Line	:	STE 202
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2024
Country	:	US
Telephone Number	:	803-256-9268
Fax Number	:	803-256-0084

Provider Business Practice Location Address
First Line	:	2750 LAUREL ST
Second Line	:	STE 202
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2024
Country	:	US
Telephone Number	:	803-256-9268
Fax Number	:	803-256-0084

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	03/19/2013

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