Provider Demographics
NPI:1265561856
Name:SOUTHEASTERN ORAL & MAXILLOFACIAL SURGERY CENTER INC
Entity type:Organization
Organization Name:SOUTHEASTERN ORAL & MAXILLOFACIAL SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-815-4546
Mailing Address - Street 1:347 RED CEDAR ST
Mailing Address - Street 2:BUILDING 200
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-8906
Mailing Address - Country:US
Mailing Address - Phone:843-815-4546
Mailing Address - Fax:
Practice Address - Street 1:347 RED CEDAR ST
Practice Address - Street 2:BUILDING 200
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8906
Practice Address - Country:US
Practice Address - Phone:843-815-4546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU740956241Medicare UPIN