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General NPI Number Information
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NPI Number | 1023234853
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Entity Type | Organization
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Legal Business Name | CENTRAL GEORGIA ORAL AND MAXILLOFACIAL SURGERY, LLC
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 740 FIRST ST.
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City | MACON
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State | GA
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Zip | 31201-6840
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Country | US
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Telephone | 478-745-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 740 FIRST ST.
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City | MACON
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State | GA
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Zip | 31201-6840
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Country | US
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Telephone | 478-745-0200
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLYDE D MARLOW
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Credential | DDS
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Telephone | 478-745-0200
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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 | 6880
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License Number State | GA
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