Healthcare Provider Details

I. General information

NPI: 1356983746
Provider Name (Legal Business Name): CORNERSTONE ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 COWART AVE
VALDOSTA GA
31602-2635
US

IV. Provider business mailing address

PO BOX 372
POOLER GA
31322-0372
US

V. Phone/Fax

Practice location:
  • Phone: 912-408-7100
  • Fax: 912-408-7101
Mailing address:
  • Phone: 912-432-0685
  • Fax: 912-408-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER MYERS
Title or Position: OWNER
Credential: DMD
Phone: 912-432-0685