Provider Demographics
NPI:1770707887
Name:UPSTATE ORAL & MAXILLOFACIAL SURGERY & DENTAL IMPLANT CENTER, P.A.
Entity type:Organization
Organization Name:UPSTATE ORAL & MAXILLOFACIAL SURGERY & DENTAL IMPLANT CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:ATALLAH
Authorized Official - Last Name:JOUDEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-855-0383
Mailing Address - Street 1:227 S PENDLETON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3047
Mailing Address - Country:US
Mailing Address - Phone:864-855-0383
Mailing Address - Fax:864-855-0390
Practice Address - Street 1:227 S PENDLETON ST
Practice Address - Street 2:SUITE A
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3047
Practice Address - Country:US
Practice Address - Phone:864-855-0383
Practice Address - Fax:864-855-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ1503Medicaid
SCZX3518Medicaid
SC1730197641OtherNPI SAMER A. JOUDEH
SCZG1698Medicaid
SC1629182506OtherNPI W. MICHAEL RIDDLE
SC1780769307OtherNPI S. ANTHONY BOWIE
SC1629182506OtherNPI W. MICHAEL RIDDLE