Provider Demographics
NPI:1215070750
Name:MEADOW, DAVID JACKSON (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JACKSON
Last Name:MEADOW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 TWO NOTCH RD STE 8
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1612
Mailing Address - Country:US
Mailing Address - Phone:803-788-3707
Mailing Address - Fax:803-788-3701
Practice Address - Street 1:9600 TWO NOTCH RD STE 8
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1612
Practice Address - Country:US
Practice Address - Phone:803-788-3707
Practice Address - Fax:803-788-3701
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ18142Medicaid