Provider Demographics
NPI:1215270970
Name:EAST GEORGIA CENTER FOR ORAL & FACIAL SURGERY LLC
Entity type:Organization
Organization Name:EAST GEORGIA CENTER FOR ORAL & FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUKETU
Authorized Official - Middle Name:J
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:912-764-5435
Mailing Address - Street 1:1222 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0849
Mailing Address - Country:US
Mailing Address - Phone:912-764-5435
Mailing Address - Fax:912-764-9789
Practice Address - Street 1:1222 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0849
Practice Address - Country:US
Practice Address - Phone:912-764-5435
Practice Address - Fax:912-764-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0145051223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty