Healthcare Provider Details

I. General information

NPI: 1093047896
Provider Name (Legal Business Name): EARL B HARTZOG DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17652 HERITAGE HWY
DENMARK SC
29042-1469
US

IV. Provider business mailing address

17652 HERITAGE HWY
DENMARK SC
29042-1469
US

V. Phone/Fax

Practice location:
  • Phone: 803-793-3653
  • Fax: 803-753-9777
Mailing address:
  • Phone: 803-793-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4591
License Number StateSC

VIII. Authorized Official

Name: DR. EARL B HARTZOG
Title or Position: PRESIDENT
Credential: DMD
Phone: 843-560-0639