MEDICARE: EXEMPLAR ORAL SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1124616974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXEMPLAR ORAL SURGERY CENTER

Provider Business Mailing Address
First Line	:	4986 CALVIN ST
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-5902
Country	:	US
Telephone Number	:	843-408-4808
Fax Number	:	843-408-4614

Provider Business Practice Location Address
First Line	:	4986 CALVIN ST
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-5902
Country	:	US
Telephone Number	:	843-408-4808
Fax Number	:	843-408-4614

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. DANIEL LEACH
Credential	:	DMD
Telephone Number	:	843-408-4808

Provider Enumeration Date	:	01/07/2021
Last Update Date	:	07/27/2021

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