Provider Demographics
NPI:1730602319
Name:SHELBOURNE & ASSOCIATES ORAL AND FACIAL SURGERY
Entity type:Organization
Organization Name:SHELBOURNE & ASSOCIATES ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHELBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-853-5859
Mailing Address - Street 1:198 RUTLEDGE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5834
Mailing Address - Country:US
Mailing Address - Phone:843-853-5859
Mailing Address - Fax:843-853-5861
Practice Address - Street 1:198 RUTLEDGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5834
Practice Address - Country:US
Practice Address - Phone:843-853-5859
Practice Address - Fax:843-853-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3426204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty