1124287552 NPI number — NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.

Table of content: (NPI 1124287552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124287552 NPI number — NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CALHOUN ORAL SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124287552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 MEMORIAL DR
Provider Second Line Business Mailing Address:
STE. 101
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-8662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-277-9393
Provider Business Mailing Address Fax Number:
706-277-9628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 MEMORIAL DR
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30720-8662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-277-9393
Provider Business Practice Location Address Fax Number:
706-277-9628
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
706-277-9393

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  011433 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000678917A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9180202 . This is a "DORAL DENTAL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 954599 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com