Provider Demographics
NPI:1689764599
Name:STOCKTON FAMILY & COSMETIC DENTISTRY PA
Entity Type:Organization
Organization Name:STOCKTON FAMILY & COSMETIC DENTISTRY PA
Other - Org Name:STOCKTON FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUGES
Authorized Official - Middle Name:F
Authorized Official - Last Name:STOCKTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-735-5446
Mailing Address - Street 1:5219 TWO NOTCH ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-735-9446
Mailing Address - Fax:803-735-9813
Practice Address - Street 1:5219 TWO NOTCH ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-735-9446
Practice Address - Fax:803-735-9813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3901Medicaid