=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073496253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ORAL SURGERY & IMPLANT SPECIALISTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2025
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3634 WHEELER RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-860-8228
-----------------------------------------------------
Fax | 706-860-7222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3634 WHEELER RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-860-8228
-----------------------------------------------------
Fax | 706-860-7222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | CLAIRE D SHIVERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-860-8228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------