Provider Demographics
NPI:1376595413
Name:ROWAN ORAL & FACIAL SURGERY PC
Entity Type:Organization
Organization Name:ROWAN ORAL & FACIAL SURGERY PC
Other - Org Name:MOORESVILLE ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:704-799-3555
Mailing Address - Street 1:858 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6852
Mailing Address - Country:US
Mailing Address - Phone:704-799-3555
Mailing Address - Fax:704-799-3095
Practice Address - Street 1:858 BRAWLEY SCHOOL RD
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6852
Practice Address - Country:US
Practice Address - Phone:704-799-3555
Practice Address - Fax:704-799-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136CUMedicaid
NC89136CUMedicaid
NC2001524AMedicare ID - Type Unspecified