Healthcare Provider Details

I. General information

NPI: 1376475541
Provider Name (Legal Business Name): MAXFACESURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 COLONY PT
SUWANEE GA
30024-3010
US

IV. Provider business mailing address

4590 COLONY PT
SUWANEE GA
30024-3010
US

V. Phone/Fax

Practice location:
  • Phone: 601-208-9064
  • Fax:
Mailing address:
  • Phone: 601-208-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RAVI CHANDRAN
Title or Position: PRESIDENT
Credential: DMD PHD FACS
Phone: 601-208-9064