Healthcare Provider Details

I. General information

NPI: 1053971861
Provider Name (Legal Business Name): JENNIFER ROSE VAN HOOK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 08/22/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3573 SUNSET BLVD
WEST COLUMBIA SC
29169-3043
US

IV. Provider business mailing address

3573 SUNSET BLVD
WEST COLUMBIA SC
29169-3043
US

V. Phone/Fax

Practice location:
  • Phone: 803-973-4530
  • Fax: 803-973-4533
Mailing address:
  • Phone: 803-973-4530
  • Fax: 803-973-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401416503
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDGD.10440
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0401416503
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0401416503
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: