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General NPI Number Information
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NPI Number | 1578596060
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Entity Type | Organization
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Legal Business Name | ORAL & MAXILLOFACIAL SURGERY CLINIC OF SOUTH MISSSISSIPPI, P.A.
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 07/22/2020
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Provider Practice Location Address
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Address Line | 1421 S 28TH AVE
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City | HATTIESBURG
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State | MS
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Zip | 39402-3108
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Country | US
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Telephone | 601-264-7611
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Fax | 601-268-0693
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Provider Business Mailing Address
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Address Line | 1421 S 28TH AVE
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City | HATTIESBURG
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State | MS
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Zip | 39402-3108
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Country | US
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Telephone | 601-264-7611
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Fax | 601-268-0693
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. SANDRA P ODOM
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Credential |
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Telephone | 601-261-9317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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