Provider Demographics
NPI:1053446328
Name:THE CENTER FOR ORAL AND MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:THE CENTER FOR ORAL AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEETS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-0300
Mailing Address - Street 1:53 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:573-335-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH45965Medicare UPIN
MOT71025Medicare UPIN