Provider Demographics
NPI:1073054177
Name:PANTAZIS, HEIDI (DMD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PANTAZIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 BROOKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5658
Mailing Address - Country:US
Mailing Address - Phone:716-870-7410
Mailing Address - Fax:
Practice Address - Street 1:4344 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4010
Practice Address - Country:US
Practice Address - Phone:803-896-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8883122300000X
GADN015311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist