Provider Demographics
NPI:1083214365
Name:ADVANCED FACIAL SURGERY AND ANESTHESIA PLLC
Entity Type:Organization
Organization Name:ADVANCED FACIAL SURGERY AND ANESTHESIA PLLC
Other - Org Name:ORAL AND FACIAL SURGERY OF THE CAROLINAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-584-8007
Mailing Address - Street 1:301 INDIAN TRAIL RD S
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9101
Mailing Address - Country:US
Mailing Address - Phone:704-839-0535
Mailing Address - Fax:
Practice Address - Street 1:301 INDIAN TRAIL RD S
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9101
Practice Address - Country:US
Practice Address - Phone:704-839-0535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1164979589Medicaid