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General NPI Number Information
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NPI Number | 1194732735
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Entity Type | Organization
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Legal Business Name | NORTHWEST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 06/22/2015
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Provider Practice Location Address
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Address Line | 55 WHITCHER ST NE SUITE 140
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City | MARIETTA
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State | GA
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Zip | 30060-1155
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Country | US
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Telephone | 770-422-7630
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Fax | 770-422-6017
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Provider Business Mailing Address
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Address Line | 55 WHITCHER ST NE SUITE 140
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City | MARIETTA
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State | GA
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Zip | 30060-1155
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Country | US
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Telephone | 770-422-7630
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Fax | 770-422-6017
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Authorized Official
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Title or Position | PRESIDENT
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Name | MANUEL A. DAVILA
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Credential |
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Telephone | 770-422-7630
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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 |
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License Number State | NULL
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