1770707887 NPI number — UPSTATE ORAL & MAXILLOFACIAL SURGERY & DENTAL IMPLANT CENTER, P.A.

Table of content: (NPI 1770707887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770707887 NPI number — UPSTATE ORAL & MAXILLOFACIAL SURGERY & DENTAL IMPLANT CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE ORAL & MAXILLOFACIAL SURGERY & DENTAL IMPLANT CENTER, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770707887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 S PENDLETON ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29640-3047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-855-0383
Provider Business Mailing Address Fax Number:
864-855-0390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 S PENDLETON ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
EASLEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29640-3047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-855-0383
Provider Business Practice Location Address Fax Number:
864-855-0390
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOUDEH
Authorized Official First Name:
SAMER
Authorized Official Middle Name:
ATALLAH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
864-855-0383

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZ1503 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZX3518 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1730197641 . This is a "NPI SAMER A. JOUDEH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: ZG1698 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629182506 . This is a "NPI W. MICHAEL RIDDLE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1780769307 . This is a "NPI S. ANTHONY BOWIE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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