Healthcare Provider Details

I. General information

NPI: 1275536245
Provider Name (Legal Business Name): EDGAR HAROLD PEACOCK JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 LAUREL ST STE 202
COLUMBIA SC
29204-2024
US

IV. Provider business mailing address

2750 LAUREL ST STE 202
COLUMBIA SC
29204-2024
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-9268
  • Fax: 803-256-0084
Mailing address:
  • Phone: 803-256-9268
  • Fax: 803-256-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1545
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: