Healthcare Provider Details

I. General information

NPI: 1942794789
Provider Name (Legal Business Name): INDIAN LAND ORAL & FACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9787 CHARLOTTE HWY
FORT MILL SC
29707-8103
US

IV. Provider business mailing address

9789 CHARLOTTE HWY STE 400-207
FORT MILL SC
29707-7177
US

V. Phone/Fax

Practice location:
  • Phone: 980-939-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LESLEY COYNER
Title or Position: CREDENTIALING
Credential:
Phone: 304-720-7819