Healthcare Provider Details

I. General information

NPI: 1568538098
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY OF ANDERSON,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 NORTH FANT STREET
ANDERSON SC
29621-4708
US

IV. Provider business mailing address

1514 NORTH FANT STREET
ANDERSON SC
29621-4708
US

V. Phone/Fax

Practice location:
  • Phone: 864-226-8559
  • Fax: 864-226-8853
Mailing address:
  • Phone: 864-226-8559
  • Fax: 864-226-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3257
License Number StateSC

VIII. Authorized Official

Name: DR. WILLIAM S. DUNLAP
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 864-226-8559