Healthcare Provider Details

I. General information

NPI: 1144358623
Provider Name (Legal Business Name): CAROLINA CTR FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 POWELL MILL RD
SPARTANBURG SC
29302-1531
US

IV. Provider business mailing address

115 POWELL MILL RD
SPARTANBURG SC
29302-1531
US

V. Phone/Fax

Practice location:
  • Phone: 864-574-2011
  • Fax: 864-576-7377
Mailing address:
  • Phone: 864-574-2011
  • Fax: 864-576-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1723
License Number StateSC

VIII. Authorized Official

Name: DR. HARRY CLINTON BELK JR.
Title or Position: PRESIDENT
Credential: DMD
Phone: 864-574-2011