Provider Demographics
NPI:1578596060
Name:ORAL & MAXILLOFACIAL SURGERY CLINIC OF SOUTH MISSSISSIPPI, P.A.
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY CLINIC OF SOUTH MISSSISSIPPI, P.A.
Other - Org Name:HATTIESBURG ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-261-9317
Mailing Address - Street 1:1421 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3108
Mailing Address - Country:US
Mailing Address - Phone:601-264-7611
Mailing Address - Fax:601-268-0693
Practice Address - Street 1:1421 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3108
Practice Address - Country:US
Practice Address - Phone:601-264-7611
Practice Address - Fax:601-268-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06271376Medicaid
MS=========OtherCLINIC'S TAX ID #
MST20923Medicare UPIN
MS=========OtherCLINIC'S TAX ID #