Healthcare Provider Details

I. General information

NPI: 1598173627
Provider Name (Legal Business Name): BLUE RIDGE ORAL AND MAXILLOFACIAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E HIGHLAND AVE
ANDERSON SC
29621-4711
US

IV. Provider business mailing address

209 E HIGHLAND AVE
ANDERSON SC
29621-4711
US

V. Phone/Fax

Practice location:
  • Phone: 843-267-5882
  • Fax:
Mailing address:
  • Phone: 843-267-5882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERIC MCGILL BRYANT SR.
Title or Position: PRESIDENT
Credential: DMD
Phone: 843-267-5882