Healthcare Provider Details

I. General information

NPI: 1386699288
Provider Name (Legal Business Name): MIDLANDS ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 SAINT JULIAN PL
COLUMBIA SC
29204-2409
US

IV. Provider business mailing address

1755 SAINT JULIAN PL
COLUMBIA SC
29204-2409
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-2972
  • Fax: 803-799-2151
Mailing address:
  • Phone: 803-254-2972
  • Fax: 803-799-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1788
License Number StateSC

VIII. Authorized Official

Name: DIANE M MONTES
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 803-254-2972