Healthcare Provider Details

I. General information

NPI: 1700234168
Provider Name (Legal Business Name): BRIAN A WOMBLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 MCDONOUGH PKWY
MCDONOUGH GA
30253-8946
US

IV. Provider business mailing address

235 EAGLES LANDING WAY
MCDONOUGH GA
30253-4221
US

V. Phone/Fax

Practice location:
  • Phone: 770-914-2808
  • Fax: 678-432-9193
Mailing address:
  • Phone: 770-914-2808
  • Fax: 678-432-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9213
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: