Provider Demographics
NPI:1275755860
Name:SOUTHEASTERN ORAL-MAXILLOFACIAL AND COSMETIC SURGERY CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN ORAL-MAXILLOFACIAL AND COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-792-2880
Mailing Address - Street 1:216 HEALTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1942
Mailing Address - Country:US
Mailing Address - Phone:334-792-2880
Mailing Address - Fax:334-792-9336
Practice Address - Street 1:216 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1942
Practice Address - Country:US
Practice Address - Phone:334-792-2880
Practice Address - Fax:334-792-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty