MEDICARE: COLUMBIA DENTAL ASSOCIATES

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	1223G0001X	General Practice Dentistry	200639953147	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	576571	OTHER	SC	MILLITARY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982773669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	2007 BROAD RIVER RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-7006
Country	:	US
Telephone Number	:	803-772-1548
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 BROAD RIVER RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-7006
Country	:	US
Telephone Number	:	803-772-1548
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BENJAMIN SHEFTALL
Credential	:	DMD
Telephone Number	:	803-772-1548

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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