Provider Demographics
NPI:1619008547
Name:GREENVILLE ORAL SURGERY, P.A.
Entity Type:Organization
Organization Name:GREENVILLE ORAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-281-9119
Mailing Address - Street 1:3929 S HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6138
Mailing Address - Country:US
Mailing Address - Phone:864-281-9119
Mailing Address - Fax:864-281-9776
Practice Address - Street 1:3929 S HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6138
Practice Address - Country:US
Practice Address - Phone:864-281-9119
Practice Address - Fax:864-281-9776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30-031941223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ 31948Medicaid