MEDICARE: THE CENTER FOR FUNCTIONAL & AESTHETIC FACIAL SURGERY

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	9900887	NC

General Provider Information

NPI Number	:	1881761583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR FUNCTIONAL & AESTHETIC FACIAL SURGERY

Provider Business Mailing Address
First Line	:	5501 FORTUNES RIDGE DR
Second Line	:	SUITE G
City	:	DURHAM
State	:	NC
Zip	:	27713-6102
Country	:	US
Telephone Number	:	919-419-9222
Fax Number	:	919-419-9255

Provider Business Practice Location Address
First Line	:	5501 FORTUNES RIDGE DR
Second Line	:	SUITE G
City	:	DURHAM
State	:	NC
Zip	:	27713-6102
Country	:	US
Telephone Number	:	919-419-9222
Fax Number	:	919-419-9255

Authorized Official
Title or Position	:	PATIENT CARE COORDINATOR
Name	:	MRS. JENNIFER THOMAS PICKETT
Credential	:
Telephone Number	:	919-419-9222

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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