Provider Demographics
NPI:1639353659
Name:IREDELL ORAL & FACIAL SURGERY PC
Entity Type:Organization
Organization Name:IREDELL ORAL & FACIAL SURGERY PC
Other - Org Name:JOHNSON ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-799-0771
Mailing Address - Street 1:229 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8543
Mailing Address - Country:US
Mailing Address - Phone:704-799-0771
Mailing Address - Fax:704-799-2941
Practice Address - Street 1:229 MEDICAL PARK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8543
Practice Address - Country:US
Practice Address - Phone:704-799-0771
Practice Address - Fax:704-799-2941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900556261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891218UMedicaid
NC1218UOtherBLUE CROSS BLUE SHIELD
NC1218UOtherBLUE CROSS BLUE SHIELD
NC891218UMedicaid