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General NPI Number Information
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NPI Number | 1215270970
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Entity Type | Organization
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Legal Business Name | EAST GEORGIA CENTER FOR ORAL & FACIAL SURGERY LLC
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Dates
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Enumeration Date | 04/01/2013
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 1222 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458-0849
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Country | US
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Telephone | 912-764-5435
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Fax | 912-764-9789
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Provider Business Mailing Address
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Address Line | 1222 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458-0849
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Country | US
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Telephone | 912-764-5435
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Fax | 912-764-9789
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Authorized Official
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Title or Position | OWNER
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Name | SUKETU J. PATEL
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Credential | DMD, MD
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Telephone | 912-764-5435
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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 | DN014505
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License Number State | GA
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