Healthcare Provider Details

I. General information

NPI: 1801920301
Provider Name (Legal Business Name): SOUTHEASTERN ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 PAULSEN ST
SAVANNAH GA
31405-4418
US

IV. Provider business mailing address

4815 PAULSEN ST
SAVANNAH GA
31405-4418
US

V. Phone/Fax

Practice location:
  • Phone: 912-352-2324
  • Fax: 912-354-0935
Mailing address:
  • Phone: 912-352-2324
  • Fax: 912-354-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MS. ELAINE LIEUPO CARTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 912-352-2324