=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700092681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIEDMONT PLASTIC & ORAL SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 JAKE ALEXANDER BLVD W SUITE 103
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28147-1384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-754-2679
-----------------------------------------------------
Fax | 704-637-2351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 JAKE ALEXANDER BLVD W SUITE 103
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28147-1384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-754-2679
-----------------------------------------------------
Fax | 704-637-2351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. SAMUEL J ROY
-----------------------------------------------------
Credential | DDS MD
-----------------------------------------------------
Telephone | 704-754-2679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------