Healthcare Provider Details

I. General information

NPI: 1467193599
Provider Name (Legal Business Name): ATLANTIC ORAL SURGERY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 MEDICAL PARK RD STE 300
MOORESVILLE NC
28117-8544
US

IV. Provider business mailing address

125 TRADE CT STE F
MOORESVILLE NC
28117-5546
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-9995
  • Fax: 704-360-2221
Mailing address:
  • Phone: 704-360-9995
  • Fax: 704-360-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MATTHEW JEFFREY JOHNSON JR.
Title or Position: PHYSICIAN
Credential: MD, MPH
Phone: 704-360-9995