Healthcare Provider Details

I. General information

NPI: 1073431144
Provider Name (Legal Business Name): ORANGEBURG ORTHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 ORANGEBURG RD STE A
SUMMERVILLE SC
29483-8941
US

IV. Provider business mailing address

953 ORANGEBURG RD STE A
SUMMERVILLE SC
29483-8941
US

V. Phone/Fax

Practice location:
  • Phone: 843-261-2001
  • Fax:
Mailing address:
  • Phone: 843-261-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNI TOMLINSON
Title or Position: CREDENTIALING AND ENROLLMENT
Credential:
Phone: 470-552-1823