Provider Demographics
NPI:1700916822
Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY CENTER
Entity Type:Organization
Organization Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NITKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-699-5900
Mailing Address - Street 1:9310 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6416
Mailing Address - Country:US
Mailing Address - Phone:803-699-5900
Mailing Address - Fax:803-788-9036
Practice Address - Street 1:9310 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6416
Practice Address - Country:US
Practice Address - Phone:803-699-5900
Practice Address - Fax:803-788-9036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31601223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9919Medicaid