Provider Demographics
NPI:1467193599
Name:ATLANTIC ORAL SURGERY CENTER, PLLC
Entity Type:Organization
Organization Name:ATLANTIC ORAL SURGERY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:704-360-9995
Mailing Address - Street 1:125 TRADE CT STE F
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5546
Mailing Address - Country:US
Mailing Address - Phone:704-360-9995
Mailing Address - Fax:704-360-2221
Practice Address - Street 1:229 MEDICAL PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8544
Practice Address - Country:US
Practice Address - Phone:704-360-9995
Practice Address - Fax:704-360-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery