Healthcare Provider Details

I. General information

NPI: 1063682680
Provider Name (Legal Business Name): VIDALIA ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MAPLE DR
VIDALIA GA
30474-8909
US

IV. Provider business mailing address

310 MAPLE DR
VIDALIA GA
30474-8909
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-4119
  • Fax: 912-537-9117
Mailing address:
  • Phone: 912-537-4119
  • Fax: 912-537-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number01415
License Number StateGA

VIII. Authorized Official

Name: DR. RONALD O MOSLEY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 912-537-4119