Provider Demographics
NPI:1093874562
Name:COASTAL ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:COASTAL ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:JEFFREY S HALL, MD, DMD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:843-569-0904
Mailing Address - Street 1:9221 UNIVERSITY BLVD
Mailing Address - Street 2:BUILDING D, SUITE 1-A
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9148
Mailing Address - Country:US
Mailing Address - Phone:843-569-0904
Mailing Address - Fax:843-569-0961
Practice Address - Street 1:9221 UNIVERSITY BLVD
Practice Address - Street 2:BUILDING D, SUITE 1-A
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9148
Practice Address - Country:US
Practice Address - Phone:843-569-0904
Practice Address - Fax:843-569-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9890Medicaid