1083677884 NPI number — SUMTER ORAL & MAXILLOFACIAL SURGERY PA

Table of content: (NPI 1083677884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083677884 NPI number — SUMTER ORAL & MAXILLOFACIAL SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMTER ORAL & MAXILLOFACIAL SURGERY PA
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:
DENTAL IMPLANT CENTER OF SUMTER
Provider Other Organization Name Type Code:
3
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:
1083677884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1210 WILSON HALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-1889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-905-4404
Provider Business Mailing Address Fax Number:
803-905-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 WILSON HALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-1889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-905-4404
Provider Business Practice Location Address Fax Number:
803-905-4406
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGINNIS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-905-4404

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3273 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 474 , 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: ZA9858 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 872701 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 88003121 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: ZDK433 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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