Healthcare Provider Details

I. General information

NPI: 1396064986
Provider Name (Legal Business Name): SMYRNA ORAL AND MAXILLOFACIAL SURGERY AND IMPLANTOLOGY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2010
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 CONCORD RD SE STE 100
SMYRNA GA
30080-4255
US

IV. Provider business mailing address

1155 CONCORD RD SE STE 100
SMYRNA GA
30080-4255
US

V. Phone/Fax

Practice location:
  • Phone: 770-435-9222
  • Fax:
Mailing address:
  • Phone: 770-435-9222
  • Fax: 770-435-9260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013667
License Number StateGA

VIII. Authorized Official

Name: DR. CECIL PHILLIP STANCIL JR.
Title or Position: CEO
Credential: D.D.S.
Phone: 615-207-1932