Healthcare Provider Details

I. General information

NPI: 1134682859
Provider Name (Legal Business Name): NORTH ATLANTA ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 WESTSIDE PKWY STE 350
ALPHARETTA GA
30004-4191
US

IV. Provider business mailing address

3275 MARKET PLACE BLVD STE 175
CUMMING GA
30041-7981
US

V. Phone/Fax

Practice location:
  • Phone: 770-664-6533
  • Fax:
Mailing address:
  • Phone: 770-406-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: PAM JEADEMANN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 770-664-6533