Provider Demographics
NPI:1265880470
Name:HACKBARTH, MALLORY JANE (DMD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:JANE
Last Name:HACKBARTH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BEN CASEY DR STE 121
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8574
Mailing Address - Country:US
Mailing Address - Phone:803-802-3681
Mailing Address - Fax:
Practice Address - Street 1:105 BEN CASEY DR STE 121
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8574
Practice Address - Country:US
Practice Address - Phone:803-802-3681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC108311223E0200X
TN105001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice