Healthcare Provider Details

I. General information

NPI: 1619008547
Provider Name (Legal Business Name): GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3929 S HIGHWAY 14
GREENVILLE SC
29615-6138
US

IV. Provider business mailing address

3929 S HIGHWAY 14
GREENVILLE SC
29615-6138
US

V. Phone/Fax

Practice location:
  • Phone: 864-281-9119
  • Fax: 864-281-9776
Mailing address:
  • Phone: 864-281-9119
  • Fax: 864-281-9776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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