Provider Demographics
NPI:1518177807
Name:ORANGEBURG ORAL SURGERY & IMPLANT CENTER
Entity Type:Organization
Organization Name:ORANGEBURG ORAL SURGERY & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AEOLAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNDERBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-534-5444
Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:STE 135
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:STE 135
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-534-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223P0106X1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty