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: 05/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 S COBB DR SE UNIT 200
SMYRNA GA
30080-7145
US

IV. Provider business mailing address

250 PARK AVENUE WEST NW UNIT 204
ATLANTA GA
30313-1603
US

V. Phone/Fax

Practice location:
  • Phone: 615-207-1932
  • Fax:
Mailing address:
  • Phone: 615-207-1932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
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