Provider Demographics
NPI:1134549629
Name:FOOTHILLS ORAL & FACIAL SURGERY
Entity type:Organization
Organization Name:FOOTHILLS ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEBEDOVYCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:864-967-4000
Mailing Address - Street 1:301 W BELTLINE BLVD
Mailing Address - Street 2:#301
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-1505
Mailing Address - Country:US
Mailing Address - Phone:864-967-4000
Mailing Address - Fax:864-328-9907
Practice Address - Street 1:301 W BELTLINE BLVD
Practice Address - Street 2:#301
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-1505
Practice Address - Country:US
Practice Address - Phone:864-967-4000
Practice Address - Fax:864-328-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1223S0112XMedicaid