Healthcare Provider Details

I. General information

NPI: 1689001034
Provider Name (Legal Business Name): EARL B HARTZOG DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 CATHERINE AVENUE NORTH
ESTILL SC
29918
US

IV. Provider business mailing address

474 NORTH ST
BAMBERG SC
29003-1318
US

V. Phone/Fax

Practice location:
  • Phone: 803-625-3640
  • Fax: 803-625-4382
Mailing address:
  • Phone: 803-245-5545
  • Fax: 803-245-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4591
License Number StateSC

VIII. Authorized Official

Name: DR. EARL B HARTZOG
Title or Position: PRESIDENT
Credential: DMD
Phone: 803-793-3653