Provider Demographics
NPI:1891744462
Name:ORAL & FACIAL SURGERY CENTER PA
Entity Type:Organization
Organization Name:ORAL & FACIAL SURGERY CENTER PA
Other - Org Name:MAXILLOFACIAL SURGERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOLDING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:479-957-4611
Mailing Address - Street 1:PO BOX 4185
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-4185
Mailing Address - Country:US
Mailing Address - Phone:479-717-1171
Mailing Address - Fax:479-927-3085
Practice Address - Street 1:3996 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5122
Practice Address - Country:US
Practice Address - Phone:479-582-3002
Practice Address - Fax:479-582-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127319680Medicaid
AR230273680Medicaid
AR239128680Medicaid