Healthcare Provider Details

I. General information

NPI: 1689647307
Provider Name (Legal Business Name): WALTER PENNINGTON WITHERSPOON JR. DDS MSO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MEDICAL CIR
WEST COLUMBIA SC
29169-3653
US

IV. Provider business mailing address

205 MEDICAL CIR
WEST COLUMBIA SC
29169-3653
US

V. Phone/Fax

Practice location:
  • Phone: 803-796-5300
  • Fax: 803-796-5301
Mailing address:
  • Phone: 803-796-5300
  • Fax: 803-796-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1304
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number94
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1304
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number94
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: