Healthcare Provider Details

I. General information

NPI: 1013235290
Provider Name (Legal Business Name): BULLOCH ORAL AND MAXILLOFACIAL SURGERY AND DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FLORENCE AVE
STATESBORO GA
30458-5138
US

IV. Provider business mailing address

301 FLORENCE AVE
STATESBORO GA
30458-5138
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-7500
  • Fax: 912-764-7503
Mailing address:
  • Phone: 912-764-7500
  • Fax: 912-764-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013413
License Number StateGA

VIII. Authorized Official

Name: DR. ROGER LEE MYERS
Title or Position: OWNER
Credential: DMD
Phone: 912-764-7500