Provider Demographics
NPI:1689001034
Name:EARL B HARTZOG DMD PA
Entity Type:Organization
Organization Name:EARL B HARTZOG DMD PA
Other - Org Name:ESTILL 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:803-793-3653
Mailing Address - Street 1:474 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1318
Mailing Address - Country:US
Mailing Address - Phone:803-245-5545
Mailing Address - Fax:803-245-5534
Practice Address - Street 1:123 CATHERINE AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:ESTILL
Practice Address - State:SC
Practice Address - Zip Code:29918
Practice Address - Country:US
Practice Address - Phone:803-625-3640
Practice Address - Fax:803-625-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty