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General NPI Number Information
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NPI Number | 1174396105
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Entity Type | Organization
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Legal Business Name | PALMETTO PERIODONTICS LLC
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Dates
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Enumeration Date | 11/01/2023
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 124 ALPINE CIR
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City | COLUMBIA
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State | SC
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Zip | 29223-6385
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Country | US
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Telephone | 803-788-0900
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Fax | 803-788-0637
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Provider Business Mailing Address
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Address Line | 124 ALPINE CIR
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City | COLUMBIA
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State | SC
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Zip | 29223-6385
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Country | US
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Telephone | 803-788-0900
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Fax | 803-788-0637
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Authorized Official
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Title or Position | OWNER/PERIODONTIST
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Name | DR. JAMES P WILSON
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Credential | DMD
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Telephone | 803-788-0900
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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 |
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License Number State |
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