Provider Demographics
NPI:1871791228
Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PA
Entity type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-366-7324
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-366-7324
Mailing Address - Fax:601-366-0228
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 225
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-366-7324
Practice Address - Fax:601-366-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty