Provider Demographics
NPI:1831250273
Name:ORANGEBURG FAMILY DENTISTRY,LLC
Entity type:Organization
Organization Name:ORANGEBURG FAMILY DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARTZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-536-6440
Mailing Address - Street 1:695 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4834
Mailing Address - Country:US
Mailing Address - Phone:803-536-6440
Mailing Address - Fax:803-268-9921
Practice Address - Street 1:695 LAUREL ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4834
Practice Address - Country:US
Practice Address - Phone:803-536-6440
Practice Address - Fax:803-268-9921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9827Medicaid