Healthcare Provider Details

I. General information

NPI: 1396397501
Provider Name (Legal Business Name): CCOFS ORAL SURGERY I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 ROCKY SLOPE RD
GREENVILLE SC
29607-3908
US

IV. Provider business mailing address

8738 UNIVERSITY CITY BLVD
CHARLOTTE NC
28213-3558
US

V. Phone/Fax

Practice location:
  • Phone: 864-751-9972
  • Fax:
Mailing address:
  • Phone: 704-295-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER RAYLE HOCK
Title or Position: RCO MANAGER
Credential:
Phone: 704-295-4653