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General NPI Number Information
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NPI Number | 1386859262
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Entity Type | Organization
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Legal Business Name | UPSTATE PERIODONTICS, PA
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Dates
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Enumeration Date | 05/13/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 214 FRONTAGE RD
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City | CLEMSON
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State | SC
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Zip | 29631-1642
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Country | US
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Telephone | 864-654-3416
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Fax | 864-654-3384
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Provider Business Mailing Address
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Address Line | PO BOX 1804
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City | CLEMSON
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State | SC
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Zip | 29633
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Country | US
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Telephone | 864-654-3416
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Fax |
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. DAVID CHRISTOPHER GARRISON SR.
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Credential | D.M.D.
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Telephone | 864-654-3416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2267
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License Number State | SC
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