Healthcare Provider Details

I. General information

NPI: 1154681195
Provider Name (Legal Business Name): LAKE OCONEE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 FOUNDERS ROW
GREENSBORO GA
30642
US

IV. Provider business mailing address

1031 FOUNDERS ROW
GREENSBORO GA
30642
US

V. Phone/Fax

Practice location:
  • Phone: 706-454-1500
  • Fax: 706-454-1501
Mailing address:
  • Phone: 706-454-1500
  • Fax: 706-454-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN012341
License Number StateGA

VIII. Authorized Official

Name: DR. DAVID CLAY MILLER
Title or Position: PRESIDENT
Credential: DDS
Phone: 706-454-1500