Healthcare Provider Details

I. General information

NPI: 1992904536
Provider Name (Legal Business Name): ROBERT JAY LAGROON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ROBERT JAY LAGROON DMD

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 HWY 7
MCCORMICK SC
29835
US

IV. Provider business mailing address

791 HWY 7
MCCORMICK SC
29835
US

V. Phone/Fax

Practice location:
  • Phone: 864-391-9100
  • Fax: 864-391-9100
Mailing address:
  • Phone: 864-391-9100
  • Fax: 864-391-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3224
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: