Healthcare Provider Details

I. General information

NPI: 1699790410
Provider Name (Legal Business Name): WILLIAM TRENT GILLESPIE DMD,MPH,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 OTT RD
COLUMBIA SC
29205-2722
US

IV. Provider business mailing address

618 OTT RD
COLUMBIA SC
29205-2722
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-1156
  • Fax: 803-256-1160
Mailing address:
  • Phone: 803-256-1156
  • Fax: 803-256-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberSC30-03734
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: