MEDICARE: COLUMBIA PERIODONTAL ASSOICATES, LLC

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	1223P0300X	Periodontics

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

General Provider Information

NPI Number	:	1548282130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA PERIODONTAL ASSOICATES, LLC

Provider Business Mailing Address
First Line	:	3527 BUSH RIVER RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-4805
Country	:	US
Telephone Number	:	803-798-0894
Fax Number	:	803-731-7887

Provider Business Practice Location Address
First Line	:	3527 BUSH RIVER RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-4805
Country	:	US
Telephone Number	:	803-798-0894
Fax Number	:	803-731-7887

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. LAUREL-JEAN M MATHIS
Credential	:	RDH
Telephone Number	:	803-798-0894

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	08/22/2020

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