Healthcare Provider Details

I. General information

NPI: 1194812339
Provider Name (Legal Business Name): COASTAL CAROLINA ORAL MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 TOWNE CENTRE PKWY
MYRTLE BEACH SC
29579
US

IV. Provider business mailing address

133 TOWNE CENTRE PKWY
MYRTLE BEACH SC
29579
US

V. Phone/Fax

Practice location:
  • Phone: 843-448-1621
  • Fax: 843-626-2501
Mailing address:
  • Phone: 843-448-1621
  • Fax: 843-626-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: WILMA POND
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 843-448-1621