Healthcare Provider Details

I. General information

NPI: 1093848368
Provider Name (Legal Business Name): CAROLINA ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BEN CASEY DR SUITE 115
FORT MILL SC
29708-8561
US

IV. Provider business mailing address

105 BEN CASEY DR SUITE 115
FORT MILL SC
29708-8561
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-9910
  • Fax: 803-548-9915
Mailing address:
  • Phone: 803-548-9910
  • Fax: 803-548-9915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3553611
License Number StateSC

VIII. Authorized Official

Name: KENNETH MARTIN BURTNER
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 803-548-9910