Healthcare Provider Details

I. General information

NPI: 1104372788
Provider Name (Legal Business Name): THOMAS RYAN SHEALY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 CHAMPION HILL ST
COLUMBIA SC
29207-6022
US

IV. Provider business mailing address

4323 HILL ST
FORT JACKSON SC
29207
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-0677
  • Fax:
Mailing address:
  • Phone: 803-751-6209
  • Fax: 803-751-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number32677
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number32677
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: