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?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE