Provider Demographics
NPI:1861550600
Name:SOUTHWEST CENTER FOR FACIAL AND ORAL SURGERY
Entity type:Organization
Organization Name:SOUTHWEST CENTER FOR FACIAL AND ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-249-0045
Mailing Address - Street 1:212 ROWLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-249-0045
Mailing Address - Fax:601-249-0105
Practice Address - Street 1:212 ROWLS DRIVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-249-0045
Practice Address - Fax:601-249-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660038Medicaid
MS00660038Medicaid