MEDICARE: SOUTH CAROLINA PERIODONTOLOGY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1598856353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CAROLINA PERIODONTOLOGY PA

Provider Business Mailing Address
First Line	:	2120 N BELTLINE BOULEVARD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-3905
Country	:	US
Telephone Number	:	803-782-0528
Fax Number	:	803-782-1036

Provider Business Practice Location Address
First Line	:	2120 N BELTLINE BOULEVARD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-3905
Country	:	US
Telephone Number	:	803-782-0528
Fax Number	:	803-782-1036

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM CLEVELAND JAMES JR.
Credential	:	DDS
Telephone Number	:	803-782-0528

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	08/22/2020

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