MEDICARE: PORT ROYAL ORAL SURGERY PA

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)	03964	SC

General Provider Information

NPI Number	:	1437365996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT ROYAL ORAL SURGERY PA

Provider Business Mailing Address
First Line	:	14 MARSHELLEN DR # B
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29902-6900
Country	:	US
Telephone Number	:	843-729-5409
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 MARSHELLEN DR # B
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29902-6900
Country	:	US
Telephone Number	:	834-729-5409
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	DR. SIMONS HANE JR.
Credential	:	DMD
Telephone Number	:	843-729-5409

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	08/22/2020

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