Healthcare Provider Details

I. General information

NPI: 1104974609
Provider Name (Legal Business Name): FOOTHILLS ORAL & FACIAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 FAIRVIEW RD BUILDING C
SIMPSONVILLE SC
29680
US

IV. Provider business mailing address

634 FAIRVIEW RD BUILDING C
SIMPSONVILLE SC
29680
US

V. Phone/Fax

Practice location:
  • Phone: 864-967-4000
  • Fax:
Mailing address:
  • Phone: 864-967-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4084
License Number StateSC

VIII. Authorized Official

Name: DR. VICTOR LEBEDOVYCH
Title or Position: PRESIDENT
Credential: DDS
Phone: 864-967-4000