Healthcare Provider Details

I. General information

NPI: 1659011914
Provider Name (Legal Business Name): ADVANCED FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427 NC 49 S SUITE 104
HARRISBURG NC
28075
US

IV. Provider business mailing address

301 INDIAN TRAIL RD S
INDIAN TRAIL NC
28079
US

V. Phone/Fax

Practice location:
  • Phone: 704-839-0535
  • Fax: 704-839-0549
Mailing address:
  • Phone: 704-839-0535
  • Fax: 704-839-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIN LAM
Title or Position: PRESIDENT
Credential: MD
Phone: 704-839-0535