Provider Demographics
NPI:1194732735
Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity type:Organization
Organization Name:NORTHWEST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-7630
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-422-7630
Mailing Address - Fax:770-422-6017
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 140
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-422-7630
Practice Address - Fax:770-422-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty