Healthcare Provider Details

I. General information

NPI: 1619636073
Provider Name (Legal Business Name): CHRISTOPHER JAMES VON BARGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4831 MIXSON AVE STE 104
NORTH CHARLESTON SC
29405-4567
US

IV. Provider business mailing address

4831 MIXSON AVE STE 104
CHARLESTON SC
29405-4567
US

V. Phone/Fax

Practice location:
  • Phone: 843-874-3136
  • Fax:
Mailing address:
  • Phone: 843-874-3136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10262
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9411
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: