Provider Demographics
NPI:1629668538
Name:SOLOMON ORAL SURGERY LLC
Entity Type:Organization
Organization Name:SOLOMON ORAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-0843
Mailing Address - Street 1:1971 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7890
Mailing Address - Country:US
Mailing Address - Phone:843-871-0842
Mailing Address - Fax:
Practice Address - Street 1:3102 N HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-6925
Practice Address - Country:US
Practice Address - Phone:843-871-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A. FREDERICK SOLOMON DMD P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8797Medicaid
SCZX9601Medicaid