Provider Demographics
NPI:1609649177
Name:OFS-SHOALS, LLC
Entity Type:Organization
Organization Name:OFS-SHOALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCILWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:256-712-5096
Mailing Address - Street 1:154 TITAN DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1197
Mailing Address - Country:US
Mailing Address - Phone:256-712-5096
Mailing Address - Fax:256-712-5097
Practice Address - Street 1:154 TITAN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1197
Practice Address - Country:US
Practice Address - Phone:256-712-5096
Practice Address - Fax:256-712-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty