Healthcare Provider Details

I. General information

NPI: 1184506693
Provider Name (Legal Business Name): GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W 4TH NORTH ST UNIT A
SUMMERVILLE SC
29483-6552
US

IV. Provider business mailing address

403 W 4TH NORTH ST UNIT A
SUMMERVILLE SC
29483-6552
US

V. Phone/Fax

Practice location:
  • Phone: 843-821-7583
  • Fax:
Mailing address:
  • Phone:
  • 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: TINA A HICKS
Title or Position: BILLING
Credential:
Phone: 864-216-7924