Provider Demographics
NPI:1902858004
Name:SOUTH MISSISSIPPI MAXILLOFACIAL SURGERY CENTER
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI MAXILLOFACIAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:WATTS, JR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-388-5925
Mailing Address - Street 1:1760 MEDICAL PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2131
Mailing Address - Country:US
Mailing Address - Phone:228-388-5925
Mailing Address - Fax:228-388-8153
Practice Address - Street 1:1760 MEDICAL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2131
Practice Address - Country:US
Practice Address - Phone:228-388-5925
Practice Address - Fax:228-388-8153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1987800Medicaid
MS1987800Medicaid
MS=========001OtherTRICARE
MS1987800Medicaid