Provider Demographics
NPI:1851543250
Name:ORAL AND FACIAL SURGERY OF MISSISSIPPI
Entity Type:Organization
Organization Name:ORAL AND FACIAL SURGERY OF MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:601-420-3223
Mailing Address - Street 1:266 KATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8801
Mailing Address - Country:US
Mailing Address - Phone:601-420-3223
Mailing Address - Fax:601-420-3054
Practice Address - Street 1:266 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8801
Practice Address - Country:US
Practice Address - Phone:601-420-3223
Practice Address - Fax:601-420-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOS34000261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU85144Medicare UPIN