Healthcare Provider Details

I. General information

NPI: 1083754865
Provider Name (Legal Business Name): PIEDMONT ORTHODONTIC ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 NORTH PINE STREET SUITE 5
SPARTANBURG SC
29302-1622
US

IV. Provider business mailing address

319 NORTH PINE STREET SUITE 5
SPARTANBURG SC
29302-1622
US

V. Phone/Fax

Practice location:
  • Phone: 864-585-8709
  • Fax: 864-585-8700
Mailing address:
  • Phone: 864-585-8709
  • Fax: 864-585-8700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number332
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberSC1930
License Number StateSC

VIII. Authorized Official

Name: DR. ERNEST JASON GARDNER JR.
Title or Position: OWNER ORTHODONTIST
Credential: DDS
Phone: 864-585-8709