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General NPI Number Information
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NPI Number | 1942794789
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Entity Type | Organization
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Legal Business Name | INDIAN LAND ORAL & FACIAL SURGERY LLC
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Dates
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Enumeration Date | 06/15/2018
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 9787 CHARLOTTE HWY
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City | FORT MILL
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State | SC
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Zip | 29707-8103
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Country | US
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Telephone | 980-939-1400
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Fax |
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Provider Business Mailing Address
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Address Line | 9789 CHARLOTTE HWY STE 400-207
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City | FORT MILL
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State | SC
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Zip | 29707-7177
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | LESLEY COYNER
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Credential |
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Telephone | 304-720-7819
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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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