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General NPI Number Information
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NPI Number | 1023347937
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Entity Type | Organization
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Legal Business Name | SOUTHWEST ORAL AND MAXILLOFACIAL SURGERY,LLC
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Dates
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Enumeration Date | 12/24/2009
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Last Update Date | 12/24/2009
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Provider Practice Location Address
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Address Line | 620 POINTE NORTH BOULEVARD
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City | ALBANY
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State | GA
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Zip | 31721
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Country | US
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Telephone | 678-350-6566
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4896
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City | CANTON
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State | GA
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Zip | 30114-0026
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Country | US
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Telephone | 678-350-6566
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER/ORAL SURGEON
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Name | DR. BRAD J HARRIS
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Credential | D.M.D.
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Telephone | 678-350-6566
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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 | DNO12915
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License Number State | GA
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