Healthcare Provider Details

I. General information

NPI: 1013723592
Provider Name (Legal Business Name): OXFORD MAXILLOFACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 S THOMAS ST STE 122
TUPELO MS
38801-5300
US

IV. Provider business mailing address

2886 S LAMAR BLVD
OXFORD MS
38655-5347
US

V. Phone/Fax

Practice location:
  • Phone: 662-690-5354
  • Fax:
Mailing address:
  • Phone: 662-236-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICOLE CARIDE
Title or Position: CREDENTIALING
Credential:
Phone: 727-784-2721