Healthcare Provider Details

I. General information

NPI: 1801160031
Provider Name (Legal Business Name): ORAL SURGERY OF WEST COBB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 STILESBORO RD NW STE 120
KENNESAW GA
30152-7737
US

IV. Provider business mailing address

5255 STILESBORO RD NW STE 120
KENNESAW GA
30152-7737
US

V. Phone/Fax

Practice location:
  • Phone: 770-499-2152
  • Fax: 770-499-2157
Mailing address:
  • Phone: 770-499-2152
  • Fax: 770-499-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013572
License Number StateGA

VIII. Authorized Official

Name: KELLIE GUFFIN
Title or Position: ADMINSITRATOR
Credential:
Phone: 770-499-2152