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General NPI Number Information
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NPI Number | 1164742466
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Entity Type | Organization
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Legal Business Name | GEORGIA ORAL AND FACIAL SURGERY,LLC
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Dates
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Enumeration Date | 06/09/2010
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Last Update Date | 06/09/2010
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Provider Practice Location Address
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Address Line | 1880 W OAK PKWY SUITE 215
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City | MARIETTA
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State | GA
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Zip | 30062-2272
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Country | US
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Telephone | 404-806-1762
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Fax |
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Provider Business Mailing Address
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Address Line | 1880 W OAK PKWY SUITE 215
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City | MARIETTA
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State | GA
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Zip | 30062-2272
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Country | US
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Telephone | 404-806-1762
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | SANDRA AGUILAR
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Credential |
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Telephone | 404-806-1762
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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 | 054541
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License Number State | GA
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