Provider Demographics
NPI:1487345344
Name:CAROLINA OMS LLC
Entity type:Organization
Organization Name:CAROLINA OMS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-548-9910
Mailing Address - Street 1:105 BEN CASEY DR STE 115
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8557
Mailing Address - Country:US
Mailing Address - Phone:803-548-9910
Mailing Address - Fax:803-548-9915
Practice Address - Street 1:105 BEN CASEY DR STE 115
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8557
Practice Address - Country:US
Practice Address - Phone:803-548-9910
Practice Address - Fax:803-548-9915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-19
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801976162OtherKENNETH BURTNER