Healthcare Provider Details

I. General information

NPI: 1336563659
Provider Name (Legal Business Name): FAMILY ORTHODONTICS OF S. CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8730 NORTHPARK BLVD STE A
NORTH CHARLESTON SC
29406-9265
US

IV. Provider business mailing address

1350 SPRING ST NW STE 600
ATLANTA GA
30309-2864
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-5533
  • Fax: 678-444-4152
Mailing address:
  • Phone: 404-389-1950
  • Fax: 678-444-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4396
License Number StateSC

VIII. Authorized Official

Name: JEANNINE BARTCH
Title or Position: MANAGER
Credential:
Phone: 404-389-1950