Provider Demographics
NPI:1437365996
Name:PORT ROYAL ORAL SURGERY PA
Entity Type:Organization
Organization Name:PORT ROYAL ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMONS
Authorized Official - Middle Name:
Authorized Official - Last Name:HANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-729-5409
Mailing Address - Street 1:14 MARSHELLEN DR # B
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6900
Mailing Address - Country:US
Mailing Address - Phone:843-729-5409
Mailing Address - Fax:
Practice Address - Street 1:14 MARSHELLEN DR # B
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6900
Practice Address - Country:US
Practice Address - Phone:834-729-5409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC039641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty