Healthcare Provider Details

I. General information

NPI: 1881015451
Provider Name (Legal Business Name): VSM COLUMBIA PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 BUSH RIVER RD
COLUMBIA SC
29210-5649
US

IV. Provider business mailing address

2302 BUSH RIVER RD
COLUMBIA SC
29210-5649
US

V. Phone/Fax

Practice location:
  • Phone: 803-798-8675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL WALKER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 404-410-1343