Healthcare Provider Details

I. General information

NPI: 1174656540
Provider Name (Legal Business Name): RIVER FALLS ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SQUIRES PT
DUNCAN SC
29334-8879
US

IV. Provider business mailing address

700 SQUIRES PT
DUNCAN SC
29334-8879
US

V. Phone/Fax

Practice location:
  • Phone: 864-486-8330
  • Fax:
Mailing address:
  • Phone: 864-486-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number3194
License Number StateSC

VIII. Authorized Official

Name: JAMES C WILSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 864-281-9119