Healthcare Provider Details

I. General information

NPI: 1164333555
Provider Name (Legal Business Name): WALLACE PERIODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PROFESSIONAL CT
SUMTER SC
29150-1927
US

IV. Provider business mailing address

3 PROFESSIONAL CT
SUMTER SC
29150-1927
US

V. Phone/Fax

Practice location:
  • Phone: 803-294-4021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CASEY CASTLE
Title or Position: DIRECTOR OF PAYOR CONTRACTS
Credential:
Phone: 912-732-1504