Healthcare Provider Details

I. General information

NPI: 1518129584
Provider Name (Legal Business Name): MICHAEL JAY BARLOW D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 ST. MARYS RD. SUITE A
ST. MARYS GA
31558
US

IV. Provider business mailing address

2400 ST. MARYS RD. SUITE A
ST. MARYS GA
31558
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-2677
  • Fax:
Mailing address:
  • Phone: 912-576-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013683
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: