Healthcare Provider Details

I. General information

NPI: 1598142341
Provider Name (Legal Business Name): SUNSET PERIODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
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 TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number826
License Number StateSC

VIII. Authorized Official

Name: DR. TRAVIS WAYNE MIZE
Title or Position: OWNER
Credential: D.M.D., M.H.S.
Phone: 317-345-3113