Healthcare Provider Details

I. General information

NPI: 1457666471
Provider Name (Legal Business Name): CAROLINA PERIODONTICS & ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 BAYSHORE DR SUITE A
ROCK HILL SC
29732-1569
US

IV. Provider business mailing address

1033 BAYSHORE DR SUITE A
ROCK HILL SC
29732-1569
US

V. Phone/Fax

Practice location:
  • Phone: 803-327-4444
  • Fax: 803-327-4443
Mailing address:
  • Phone: 803-327-4444
  • Fax: 803-327-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDENTAL: 4658
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDENTAL: 4667
License Number StateSC

VIII. Authorized Official

Name: DR. CHAD ROBERT MATTHEWS
Title or Position: PERIODONTIST/OWNER
Credential: DMD
Phone: 803-579-0026