Provider Demographics
NPI:1194812339
Name:COASTAL CAROLINA ORAL MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:COASTAL CAROLINA ORAL MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:POND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-448-1621
Mailing Address - Street 1:133 TOWNE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579
Mailing Address - Country:US
Mailing Address - Phone:843-448-1621
Mailing Address - Fax:843-626-2501
Practice Address - Street 1:133 TOWNE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-448-1621
Practice Address - Fax:843-626-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery