Healthcare Provider Details

I. General information

NPI: 1265682686
Provider Name (Legal Business Name): TRAVIS WAYNE MIZE D.M.D., M.H.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MEDICAL CIR
WEST COLUMBIA SC
29169-3655
US

IV. Provider business mailing address

159 MEDICAL CIR
WEST COLUMBIA SC
29169-3655
US

V. Phone/Fax

Practice location:
  • Phone: 803-794-7520
  • Fax:
Mailing address:
  • Phone: 803-794-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4466
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN1855503
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number826
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: