Healthcare Provider Details

I. General information

NPI: 1942403795
Provider Name (Legal Business Name): WEST GA ORAL SURGERY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1587 VERNON RD
LAGRANGE GA
30240-4146
US

IV. Provider business mailing address

1587 VERNON RD
LAGRANGE GA
30240-4146
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-2655
  • Fax:
Mailing address:
  • Phone: 706-884-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number8424
License Number StateGA

VIII. Authorized Official

Name: WILLIAM P HINES
Title or Position: OWNER
Credential:
Phone: 706-884-2655