=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184506693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W 4TH NORTH ST UNIT A
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29483-6552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-821-7583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W 4TH NORTH ST UNIT A
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29483-6552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | TINA A HICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-216-7924
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------