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General NPI Number Information
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NPI Number | 1013288786
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Entity Type | Organization
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Legal Business Name | PERIODONTAL ASSOCIATES LLC
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Dates
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Enumeration Date | 01/26/2012
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Last Update Date | 01/26/2012
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Provider Practice Location Address
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Address Line | 33 GAMECOCK AVE STE A
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City | CHARLESTON
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State | SC
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Zip | 29407-3397
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Country | US
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Telephone | 843-571-0853
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Fax | 843-769-7342
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Provider Business Mailing Address
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Address Line | 33 GAMECOCK AVE STE A
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City | CHARLESTON
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State | SC
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Zip | 29407-3397
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Country | US
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Telephone | 843-571-0853
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Fax | 843-769-7342
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Authorized Official
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Title or Position | MEMBER
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Name | DR. EDWARD THOMAS MURPHY
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Credential | DMD
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Telephone | 843-571-0853
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 1487
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3204
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3981
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License Number State | SC
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