Provider Demographics
NPI:1538279757
Name:GASTON ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:GASTON ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:GASTON ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:LEDFORD
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:704-865-7603
Mailing Address - Street 1:GASTON ORAL & MAXILLOFACIAL SURGERY
Mailing Address - Street 2:571 COX ROAD
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0632
Mailing Address - Country:US
Mailing Address - Phone:704-865-7603
Mailing Address - Fax:704-865-6411
Practice Address - Street 1:GASTON ORAL & MAXILLOFACIAL SURGERY
Practice Address - Street 2:571 COX ROAD
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0632
Practice Address - Country:US
Practice Address - Phone:704-865-7603
Practice Address - Fax:704-865-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC90868OtherBCBS PROVIDER NUMBER
NC94489OtherBCBS PROVIDER NUMBER
NC8990868Medicaid
NC8994489Medicaid
NC94489OtherBCBS PROVIDER NUMBER
NCT-63778Medicare UPIN
NC241020Medicare ID - Type UnspecifiedMEDICARE
NC94489OtherBCBS PROVIDER NUMBER