Healthcare Provider Details

I. General information

NPI: 1073784880
Provider Name (Legal Business Name): SOUTHERN ORAL AND MAXILLOFACIAL SURGERY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 MISSION PARK DR
VICKSBURG MS
39180-3747
US

IV. Provider business mailing address

1205 MISSION PARK DR
VICKSBURG MS
39180-3747
US

V. Phone/Fax

Practice location:
  • Phone: 601-661-0034
  • Fax: 601-661-0367
Mailing address:
  • Phone: 601-661-0034
  • Fax: 601-661-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2951-96
License Number StateMS

VIII. Authorized Official

Name: DR. KEVIN KEITH KEEN
Title or Position: SURGEON/OWNER
Credential: DMD
Phone: 601-661-0034