Healthcare Provider Details

I. General information

NPI: 1033532262
Provider Name (Legal Business Name): THE BRACES PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 LONGTOWN RD SUITE B
COLUMBIA SC
29229-9498
US

IV. Provider business mailing address

921 LONGTOWN RD SUITE B
COLUMBIA SC
29229-9498
US

V. Phone/Fax

Practice location:
  • Phone: 803-661-8468
  • Fax:
Mailing address:
  • Phone: 803-661-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30-2494
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number4641765
License Number StateSC

VIII. Authorized Official

Name: DR. ROBERT F. GARRISON
Title or Position: OWNER
Credential:
Phone: 803-661-8468