Healthcare Provider Details

I. General information

NPI: 1134549629
Provider Name (Legal Business Name): FOOTHILLS ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BELTLINE BLVD #301
ANDERSON SC
29625-1505
US

IV. Provider business mailing address

301 W BELTLINE BLVD #301
ANDERSON SC
29625-1505
US

V. Phone/Fax

Practice location:
  • Phone: 864-967-4000
  • Fax: 864-328-9907
Mailing address:
  • Phone: 864-967-4000
  • Fax: 864-328-9907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4084
License Number StateSC

VIII. Authorized Official

Name: VICTOR P LEBEDOVYCH
Title or Position: PRESIDENT/CEO
Credential: DDS
Phone: 864-967-4000