Provider Demographics
NPI:1083754865
Name:PIEDMONT ORTHODONTIC ASSOCIATES PA
Entity Type:Organization
Organization Name:PIEDMONT ORTHODONTIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-585-8709
Mailing Address - Street 1:319 NORTH PINE STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1622
Mailing Address - Country:US
Mailing Address - Phone:864-585-8709
Mailing Address - Fax:864-585-8700
Practice Address - Street 1:319 NORTH PINE STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1622
Practice Address - Country:US
Practice Address - Phone:864-585-8709
Practice Address - Fax:864-585-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3321223X0400X
SCSC19301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T23995Medicare UPIN