Healthcare Provider Details

I. General information

NPI: 1568655702
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 CLIFFORD DR
SHALIMAR FL
32579-1250
US

IV. Provider business mailing address

7 CLIFFORD DR
SHALIMAR FL
32579-1250
US

V. Phone/Fax

Practice location:
  • Phone: 850-651-6882
  • Fax: 850-651-6692
Mailing address:
  • Phone: 850-651-6882
  • Fax: 850-651-6692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN0012590
License Number StateFL

VIII. Authorized Official

Name: DR. CHARLES WILLIAM ELWELL JR.
Title or Position: OWNER
Credential: D.M.D.
Phone: 850-651-6882