Provider Demographics
NPI:1851725816
Name:VAN METER ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:VAN METER ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:VAN METER
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:601-825-0021
Mailing Address - Street 1:300 MAXEY DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2576
Mailing Address - Country:US
Mailing Address - Phone:601-825-0021
Mailing Address - Fax:601-825-0081
Practice Address - Street 1:300 MAXEY DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2576
Practice Address - Country:US
Practice Address - Phone:601-825-0021
Practice Address - Fax:601-825-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOS-466-131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty