Provider Demographics
NPI:1184506693
Name:GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
Entity type:Organization
Organization Name:GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-216-7924
Mailing Address - Street 1:403 W 4TH NORTH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 W 4TH NORTH ST UNIT A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6552
Practice Address - Country:US
Practice Address - Phone:843-821-7583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENVILLE ORAL MAXILLOFACIAL SURGERY, P.A., A SOUTH CAROLINA PROFESSI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty