Healthcare Provider Details

I. General information

NPI: 1124287552
Provider Name (Legal Business Name): NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 MEMORIAL DR STE. 101
DALTON GA
30720-8662
US

IV. Provider business mailing address

1107 MEMORIAL DR STE. 101
DALTON GA
30720-8662
US

V. Phone/Fax

Practice location:
  • Phone: 706-277-9393
  • Fax: 706-277-9628
Mailing address:
  • Phone: 706-277-9393
  • Fax: 706-277-9628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number011433
License Number StateGA

VIII. Authorized Official

Name: MRS. MISTY DAWN JAMES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-277-9393