Provider Demographics
NPI:1073784880
Name:SOUTHERN ORAL AND MAXILLOFACIAL SURGERY CENTER, INC
Entity Type:Organization
Organization Name:SOUTHERN ORAL AND MAXILLOFACIAL SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:KEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-661-0034
Mailing Address - Street 1:1205 MISSION PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3747
Mailing Address - Country:US
Mailing Address - Phone:601-661-0034
Mailing Address - Fax:601-661-0367
Practice Address - Street 1:1205 MISSION PARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3747
Practice Address - Country:US
Practice Address - Phone:601-661-0034
Practice Address - Fax:601-661-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2951-961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU80152Medicare UPIN