Provider Demographics
NPI:1396064986
Name:SMYRNA ORAL AND MAXILLOFACIAL SURGERY AND IMPLANTOLOGY CENTER, LLC
Entity type:Organization
Organization Name:SMYRNA ORAL AND MAXILLOFACIAL SURGERY AND IMPLANTOLOGY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:STANCIL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-207-1932
Mailing Address - Street 1:250 PARK AVENUE WEST NW
Mailing Address - Street 2:UNIT 204
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30313-1603
Mailing Address - Country:US
Mailing Address - Phone:615-207-1932
Mailing Address - Fax:
Practice Address - Street 1:4849 S COBB DR SE
Practice Address - Street 2:UNIT 200
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7145
Practice Address - Country:US
Practice Address - Phone:615-207-1932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-23
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013667261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery