Provider Demographics
NPI:1548792617
Name:EARL B HARTZOG DMD PA
Entity Type:Organization
Organization Name:EARL B HARTZOG DMD PA
Other - Org Name:ST MATTHEWS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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:843-560-1543
Mailing Address - Street 1:735 HARRY C RAYSOR DR
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-8403
Mailing Address - Country:US
Mailing Address - Phone:803-874-2243
Mailing Address - Fax:
Practice Address - Street 1:735 HARRY C RAYSOR DR
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-8403
Practice Address - Country:US
Practice Address - Phone:803-874-2243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EARL B HARTZOG DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-29
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty