Provider Demographics
NPI:1780466300
Name:SOUTH MISSISSIPPI ORAL SURGERY & IMPLANT CENTER PLLC
Entity type:Organization
Organization Name:SOUTH MISSISSIPPI ORAL SURGERY & IMPLANT CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-264-7611
Mailing Address - Street 1:1421 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3108
Mailing Address - Country:US
Mailing Address - Phone:601-264-7611
Mailing Address - Fax:601-268-0693
Practice Address - Street 1:12231 BERNARD PKWY
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5086
Practice Address - Country:US
Practice Address - Phone:601-264-7611
Practice Address - Fax:601-268-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty