Provider Demographics
NPI:1366577389
Name:UPSTATE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity type:Organization
Organization Name:UPSTATE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WIILIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-585-3318
Mailing Address - Street 1:280 NORTH GROVE MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4222
Mailing Address - Country:US
Mailing Address - Phone:864-585-3318
Mailing Address - Fax:864-585-4800
Practice Address - Street 1:280 NORTH GROVE MEDICAL PARK DR.
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4222
Practice Address - Country:US
Practice Address - Phone:864-585-3318
Practice Address - Fax:864-585-4800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPSTATE ORAL AND MAXILLOFACIAL SURGERY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21431223S0112X
SC21211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9899Medicaid
SCZ21218Medicaid
SCZ21432Medicaid
SCZ21432Medicaid