MEDICARE: ORANGEBURG ORAL SURGERY & IMPLANT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0106X	Oral and Maxillofacial Pathology Dentistry	1223P0106X	SC

General Provider Information

NPI Number	:	1518177807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORANGEBURG ORAL SURGERY & IMPLANT CENTER

Provider Business Mailing Address
First Line	:	1175 COOK RD
Second Line	:	STE 135
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-8201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1175 COOK RD
Second Line	:	STE 135
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-8201
Country	:	US
Telephone Number	:	803-534-5444
Fax Number	:

Authorized Official
Title or Position	:	RECEPTIONIST
Name	:	MRS. AEOLAIN FUNDERBURG
Credential	:
Telephone Number	:	803-534-5444

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	06/30/2008

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Directions to “ORANGEBURG ORAL SURGERY & IMPLANT CENTER ” Practice Location

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