Healthcare Provider Details

I. General information

NPI: 1578009056
Provider Name (Legal Business Name): SOUTHERN ROOTS PERIODONTICS: IMPLANT & LASER DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 N BELTLINE BLVD
COLUMBIA SC
29204-4518
US

IV. Provider business mailing address

2120 N BELTLINE BLVD
COLUMBIA SC
29204-4518
US

V. Phone/Fax

Practice location:
  • Phone: 803-782-0528
  • Fax: 803-782-1036
Mailing address:
  • Phone: 803-782-0528
  • Fax: 803-782-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number8489
License Number StateSC

VIII. Authorized Official

Name: DR. MATTHEW JOSEPH ROWE
Title or Position: OWNER/MANAGER
Credential: D.D.S., M.S.D.
Phone: 803-782-0528