Healthcare Provider Details

I. General information

NPI: 1295652287
Provider Name (Legal Business Name): GA JAW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-676-2550
  • Fax: 770-676-2560
Mailing address:
  • Phone: 770-676-2550
  • Fax: 770-676-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SAM CARUSO
Title or Position: OWNER/PRINCIPAL
Credential: DMD
Phone: 847-542-8131