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General NPI Number Information
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NPI Number | 1073054177
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Entity Type | Individual
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Provider Name | HEIDI PANTAZIS D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/09/2017
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Last Update Date | 03/09/2017
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Provider Practice Location Address
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Address Line | 4344 BROAD RIVER RD
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City | COLUMBIA
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State | SC
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Zip | 29210-4010
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Country | US
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Telephone | 803-896-1521
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Fax |
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Provider Business Mailing Address
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Address Line | 1227 BROOKSTONE WAY
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City | AUGUSTA
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State | GA
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Zip | 30909-5658
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Country | US
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Telephone | 716-870-7410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8883
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN015311
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License Number State | GA
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