Provider Demographics
NPI:1124287552
Name:NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.
Entity type:Organization
Organization Name:NORTH GEORGIA CENTER FOR CORRECTIVE JAW SURGERY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-277-9393
Mailing Address - Street 1:1107 MEMORIAL DR
Mailing Address - Street 2:STE. 101
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-277-9393
Mailing Address - Fax:706-277-9628
Practice Address - Street 1:1107 MEMORIAL DR
Practice Address - Street 2:STE. 101
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-277-9393
Practice Address - Fax:706-277-9628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0114331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000678917AMedicaid
GA9180202OtherDORAL DENTAL
GA954599OtherUNITED CONCORDIA