Provider Demographics
NPI:1902908338
Name:RENEE G SHONGO DMD PA
Entity Type:Organization
Organization Name:RENEE G SHONGO DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:803-794-0905
Mailing Address - Street 1:163 MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3655
Mailing Address - Country:US
Mailing Address - Phone:803-794-0905
Mailing Address - Fax:803-794-5472
Practice Address - Street 1:163 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-794-0905
Practice Address - Fax:803-794-5472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty