Provider Demographics
NPI:1093047896
Name:EARL B HARTZOG DMD PA
Entity Type:Organization
Organization Name:EARL B HARTZOG DMD PA
Other - Org Name:DENMARK DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARTZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-560-0639
Mailing Address - Street 1:17652 HERITAGE HWY
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:SC
Mailing Address - Zip Code:29042-1469
Mailing Address - Country:US
Mailing Address - Phone:803-793-3653
Mailing Address - Fax:
Practice Address - Street 1:17652 HERITAGE HWY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:SC
Practice Address - Zip Code:29042-1469
Practice Address - Country:US
Practice Address - Phone:803-793-3653
Practice Address - Fax:803-753-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4591122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4591Medicaid