# COASTAL CAROLINA ORAL MAXILLOFACIAL SURGERY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194812339
- **Authorized official:** WILMA POND (PRACTICE ADMINISTRATOR)
- **Authorized official phone:** (843) 448-1621

## Contact information

- **Practice address:** 133 TOWNE CENTRE PKWY, MYRTLE BEACH, SC 29579
- **Practice address phone:** (843) 448-1621
- **Practice address fax:** (843) 626-2501
- **Mailing address:** 133 TOWNE CENTRE PKWY, MYRTLE BEACH, SC 29579
- **Mailing address phone:** (843) 448-1621
- **Mailing address fax:** (843) 626-2501

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |
| 261QS0112X | Oral and Maxillofacial Surgery Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 10/09/2006
- **Last updated:** 04/11/2024