MEDICARE: THE CENTER FOR ORAL AND MAXILLOFACIAL SURGERY LLC

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)	12546	MO

General Provider Information

NPI Number	:	1386763936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR ORAL AND MAXILLOFACIAL SURGERY LLC

Provider Business Mailing Address
First Line	:	936 IDA ST
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-4210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	936 IDA ST
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-4210
Country	:	US
Telephone Number	:	573-785-8471
Fax Number	:

Authorized Official
Title or Position	:	ORAL SURGEON
Name	:	JOHN SHEETS
Credential	:
Telephone Number	:	573-785-8471

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/22/2020

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