Healthcare Provider Details

I. General information

NPI: 1851543250
Provider Name (Legal Business Name): ORAL AND FACIAL SURGERY OF MISSISSIPPI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 KATHERINE DR
FLOWOOD MS
39232-8801
US

IV. Provider business mailing address

266 KATHERINE DR
FLOWOOD MS
39232-8801
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-3223
  • Fax: 601-420-3054
Mailing address:
  • Phone: 601-420-3223
  • Fax: 601-420-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberOS34000
License Number StateMS

VIII. Authorized Official

Name: DR. MICHAEL R NICHOLS
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 601-420-3223