Healthcare Provider Details

I. General information

NPI: 1639353659
Provider Name (Legal Business Name): IREDELL ORAL & FACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 MEDICAL PARK RD SUITE 310
MOORESVILLE NC
28117-8543
US

IV. Provider business mailing address

229 MEDICAL PARK RD SUITE 310
MOORESVILLE NC
28117-8543
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-0771
  • Fax: 704-799-2941
Mailing address:
  • Phone: 704-799-0771
  • Fax: 704-799-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number9900556
License Number StateNC

VIII. Authorized Official

Name: MRS. KELLY MCCARTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-799-0771