Provider Demographics
NPI:1972718898
Name:ORAL AND MAXILLOFACIAL SURGERY ASSOC.PA
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY ASSOC.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-591-3500
Mailing Address - Street 1:1325 DRAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-5106
Mailing Address - Country:US
Mailing Address - Phone:864-591-3500
Mailing Address - Fax:864-591-2235
Practice Address - Street 1:1325 DRAYTON RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-5106
Practice Address - Country:US
Practice Address - Phone:864-591-3500
Practice Address - Fax:864-591-2235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ30395Medicaid
SCU33519Medicare UPIN