Healthcare Provider Details

I. General information

NPI: 1215270970
Provider Name (Legal Business Name): EAST GEORGIA CENTER FOR ORAL & FACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 BRAMPTON AVE
STATESBORO GA
30458-0849
US

IV. Provider business mailing address

1222 BRAMPTON AVE
STATESBORO GA
30458-0849
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-5435
  • Fax: 912-764-9789
Mailing address:
  • Phone: 912-764-5435
  • Fax: 912-764-9789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN014505
License Number StateGA

VIII. Authorized Official

Name: SUKETU J. PATEL
Title or Position: OWNER
Credential: DMD, MD
Phone: 912-764-5435