Provider Demographics
NPI:1407067473
Name:NORTHEAST ORAL & MAXILLOFACIAL
Entity type:Organization
Organization Name:NORTHEAST ORAL & MAXILLOFACIAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LASSETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-699-5900
Mailing Address - Street 1:1118 GREENLAWN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1118 GREENLAWN DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-2606
Practice Address - Country:US
Practice Address - Phone:803-695-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty