Healthcare Provider Details

I. General information

NPI: 1912196684
Provider Name (Legal Business Name): PALMETTO FAMILY ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HALTON VILLAGE CIR SUITE B
GREENVILLE SC
29607-6833
US

IV. Provider business mailing address

105 HALTON VILLAGE CIR SUITE B
GREENVILLE SC
29607-6833
US

V. Phone/Fax

Practice location:
  • Phone: 864-335-0505
  • Fax: 864-335-0508
Mailing address:
  • Phone: 864-335-0505
  • Fax: 864-335-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4287
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number681
License Number StateSC

VIII. Authorized Official

Name: DR. DAVID F WATSON III
Title or Position: CO-OWNER
Credential: DMD MPH
Phone: 864-335-0505