MEDICARE: SMYRNA ORAL AND MAXILLOFACIAL SURGERY AND IMPLANTOLOGY CENTER, LLC

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)	DN013667	GA

General Provider Information

NPI Number	:	1396064986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMYRNA ORAL AND MAXILLOFACIAL SURGERY AND IMPLANTOLOGY CENTER, LLC

Provider Business Mailing Address
First Line	:	1155 CONCORD RD SE STE 100
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-4255
Country	:	US
Telephone Number	:	770-435-9222
Fax Number	:	770-435-9260

Provider Business Practice Location Address
First Line	:	1155 CONCORD RD SE STE 100
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-4255
Country	:	US
Telephone Number	:	770-435-9222
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CECIL PHILLIP STANCIL JR.
Credential	:	D.D.S.
Telephone Number	:	615-207-1932

Provider Enumeration Date	:	05/23/2010
Last Update Date	:	06/16/2026

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