Healthcare Provider Details

I. General information

NPI: 1093619462
Provider Name (Legal Business Name): GWINNETT CENTER FOR ORAL & MAXILLOFACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 COLLINS INDUSTRIAL WAY SUITE B
LAWRENCEVILLE GA
30043
US

IV. Provider business mailing address

15 COLLINS INDUSTRIAL WAY SUITE B
LAWRENCEVILLE GA
30043
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-0515
  • Fax: 770-962-1244
Mailing address:
  • Phone: 770-962-0515
  • Fax: 770-962-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ASIF TAUFIG
Title or Position: OWNER
Credential: DDS
Phone: 770-962-0515