Healthcare Provider Details

I. General information

NPI: 1043409063
Provider Name (Legal Business Name): CHARLESTON ORAL AND FACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 INGLESIDE BLVD
LADSON SC
29456-4141
US

IV. Provider business mailing address

3700 INGLESIDE BLVD STE 1
LADSON SC
29456-4141
US

V. Phone/Fax

Practice location:
  • Phone: 843-762-9028
  • Fax:
Mailing address:
  • Phone: 843-762-9028
  • Fax: 843-762-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4006
License Number StateSC

VIII. Authorized Official

Name: JACKIE HOLLOWAY
Title or Position: DIRECTOR OF RCM
Credential:
Phone: 854-200-7970