Provider Demographics
NPI:1437763661
Name:CHARLESTON JAW SURGERY
Entity Type:Organization
Organization Name:CHARLESTON JAW SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-853-5859
Mailing Address - Street 1:846 ST. ANDREWS BLVD.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-853-5859
Mailing Address - Fax:843-853-5861
Practice Address - Street 1:846 ST. ANDREWS BLVD.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-853-5859
Practice Address - Fax:843-853-5861
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBOURNE & ASSOCIATES ORAL & FACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty