Healthcare Provider Details

I. General information

NPI: 1841469210
Provider Name (Legal Business Name): MACON ORAL AND MAXILLOFACIAL SURGERY,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ARKWRIGHT LNDG
MACON GA
31210-1364
US

IV. Provider business mailing address

112 ARKWRIGHT LNDG
MACON GA
31210-1364
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-9779
  • Fax: 478-471-9754
Mailing address:
  • Phone: 478-471-9779
  • Fax: 478-471-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number011926
License Number StateGA

VIII. Authorized Official

Name: DONA GURLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 478-471-9779