Healthcare Provider Details

I. General information

NPI: 1528314465
Provider Name (Legal Business Name): HERITAGE FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 SAINT MATTHEWS ROAD
SWANSEA SC
29160
US

IV. Provider business mailing address

533 SAINT MATTHEWS ROAD
SWANSEA SC
29160
US

V. Phone/Fax

Practice location:
  • Phone: 803-568-2077
  • Fax:
Mailing address:
  • Phone: 803-568-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4024
License Number StateSC

VIII. Authorized Official

Name: DR. JASON SCOTT ROGERS
Title or Position: MEMBER
Credential: DMD
Phone: 803-568-2077