MEDICARE: PEACHTREE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	010603	GA

General Provider Information

NPI Number	:	1063471324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES

Provider Business Mailing Address
First Line	:	550 PHARR RD NE
Second Line	:	SUITE 325
City	:	ATLANTA
State	:	GA
Zip	:	30305-3428
Country	:	US
Telephone Number	:	404-233-8221
Fax Number	:	404-233-5783

Provider Business Practice Location Address
First Line	:	550 PHARR RD NE
Second Line	:	SUITE 325
City	:	ATLANTA
State	:	GA
Zip	:	30305-3428
Country	:	US
Telephone Number	:	404-233-8221
Fax Number	:	404-233-5783

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREGORY P. MARKS
Credential	:	D.D.S.
Telephone Number	:	404-233-8221

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	11/15/2016

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