Healthcare Provider Details

I. General information

NPI: 1558115485
Provider Name (Legal Business Name): NORTH GEORGIA ORAL AND FACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 MCCLURE BRIDGE RD BLDG G, SUITES B AND C
DULUTH GA
30096
US

IV. Provider business mailing address

5198 DINANT DR
JOHNS CREEK GA
30022-6532
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-8576
  • Fax:
Mailing address:
  • Phone: 248-914-1691
  • Fax:

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: DR. RAMANI GOWDUCHERUVU
Title or Position: OWNER-ORAL AND MAXILLOFACIAL SURGEO
Credential: DDS
Phone: 248-914-1691