Provider Demographics
NPI:1043409063
Name:CHARLESTON ORAL AND FACIAL SURGERY, INC.
Entity Type:Organization
Organization Name:CHARLESTON ORAL AND FACIAL SURGERY, INC.
Other - Org Name:CHARLESTON CENTER FOR ORAL & FACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:STRAUSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:843-762-9028
Mailing Address - Street 1:125C WAPPOO CREEK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2163
Mailing Address - Country:US
Mailing Address - Phone:843-762-9028
Mailing Address - Fax:843-762-9030
Practice Address - Street 1:125 WAPPOO CREEK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2163
Practice Address - Country:US
Practice Address - Phone:843-762-9028
Practice Address - Fax:843-762-9030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON ORAL AND FACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-16
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA08698263Medicare PIN