Provider Demographics
NPI: | 1851090575 |
---|---|
Name: | PARK CIRCLE ORTHODONTICS, LLC |
Entity Type: | Organization |
Organization Name: | PARK CIRCLE ORTHODONTICS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHRISTOPHER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VON BARGEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 585-261-7414 |
Mailing Address - Street 1: | 4831 MIXSON AVE STE 104 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORTH CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29405-4567 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-874-3136 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4831 MIXSON AVE STE 104 |
Practice Address - Street 2: | |
Practice Address - City: | NORTH CHARLESTON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29405-4567 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-874-3136 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-03-02 |
Last Update Date: | 2023-03-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NONE | Other | NONE |