Provider Demographics
NPI:1124595475
Name:GREATER CHARLOTTE ORAL & FACIAL SURGERY
Entity Type:Organization
Organization Name:GREATER CHARLOTTE ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-542-9600
Mailing Address - Street 1:10042 PARK CEDAR DR STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8917
Mailing Address - Country:US
Mailing Address - Phone:704-542-9600
Mailing Address - Fax:704-542-9651
Practice Address - Street 1:527 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4040
Practice Address - Country:US
Practice Address - Phone:704-542-9600
Practice Address - Fax:704-215-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty