# COLUMBIA PERIODONTAL ASSOICATES, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1548282130
- **Authorized official:** MRS. LAUREL-JEAN M MATHIS RDH (OFFICE MANAGER)
- **Authorized official phone:** (803) 798-0894

## Contact information

- **Practice address:** 3527 BUSH RIVER RD, COLUMBIA, SC 29210-4805
- **Practice address phone:** (803) 798-0894
- **Practice address fax:** (803) 731-7887
- **Mailing address:** 3527 BUSH RIVER RD, COLUMBIA, SC 29210-4805
- **Mailing address phone:** (803) 798-0894
- **Mailing address fax:** (803) 731-7887

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0300X | Periodontics | — | NULL | Yes |
| 1223P0300X | Periodontics | — | — | Yes |

## Other

- **Enumeration date:** 07/24/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | ZA9736 | — | SC |