Healthcare Provider Details

I. General information

NPI: 1326178716
Provider Name (Legal Business Name): KENT WINGARD WASHINGTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7621 TRENHOLM ROAD EXT
COLUMBIA SC
29223-1719
US

IV. Provider business mailing address

7621 TRENHOLM ROAD EXT
COLUMBIA SC
29223-1719
US

V. Phone/Fax

Practice location:
  • Phone: 803-699-9989
  • Fax: 803-699-8035
Mailing address:
  • Phone: 803-699-9989
  • Fax: 803-699-8035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2554
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: