Healthcare Provider Details

I. General information

NPI: 1770736415
Provider Name (Legal Business Name): ST CROIX ORAL AND FACIAL HEALTHCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 10571
KINGSHILL VI
00850-9604
US

IV. Provider business mailing address

RR 2 BOX 10571
KINGSHILL VI
00850-9604
US

V. Phone/Fax

Practice location:
  • Phone: 340-719-3864
  • Fax: 340-719-3865
Mailing address:
  • Phone: 340-719-3864
  • Fax: 340-719-3865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number1057
License Number StateVI

VIII. Authorized Official

Name: DR. HORACE GRIFFITH
Title or Position: OWNER
Credential: DDS
Phone: 340-719-3864