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General NPI Number Information
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NPI Number | 1013235290
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Entity Type | Organization
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Legal Business Name | BULLOCH ORAL AND MAXILLOFACIAL SURGERY AND DENTAL IMPLANT CENTER
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Dates
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Enumeration Date | 05/12/2010
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Last Update Date | 05/12/2010
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Provider Practice Location Address
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Address Line | 301 FLORENCE AVE
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City | STATESBORO
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State | GA
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Zip | 30458-5138
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Country | US
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Telephone | 912-764-7500
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Fax | 912-764-7503
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Provider Business Mailing Address
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Address Line | 301 FLORENCE AVE
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City | STATESBORO
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State | GA
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Zip | 30458-5138
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Country | US
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Telephone | 912-764-7500
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Fax | 912-764-7503
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROGER LEE MYERS
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Credential | DMD
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Telephone | 912-764-7500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN013413
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License Number State | GA
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