Healthcare Provider Details

I. General information

NPI: 1548450794
Provider Name (Legal Business Name): ORAL & FACIAL SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOSPITAL DR
COLUMBUS MS
39705-1921
US

IV. Provider business mailing address

300 HOSPITAL DR
COLUMBUS MS
39705-1921
US

V. Phone/Fax

Practice location:
  • Phone: 662-327-2100
  • Fax: 662-327-2105
Mailing address:
  • Phone: 662-327-2100
  • Fax: 662-327-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1834-79
License Number StateMS

VIII. Authorized Official

Name: JOHN EDGAR GRIFFIN JR.
Title or Position: PRESIDNET
Credential: DMD
Phone: 662-327-2100