Healthcare Provider Details

I. General information

NPI: 1700916822
Provider Name (Legal Business Name): NORTHEAST ORAL & MAXILLOFACIAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9310 TWO NOTCH RD
COLUMBIA SC
29223-6416
US

IV. Provider business mailing address

9310 TWO NOTCH RD
COLUMBIA SC
29223-6416
US

V. Phone/Fax

Practice location:
  • Phone: 803-699-5900
  • Fax: 803-788-9036
Mailing address:
  • Phone: 803-699-5900
  • Fax: 803-788-9036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number3160
License Number StateSC

VIII. Authorized Official

Name: MS. EVELYN NITKA
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-699-5900