Provider Demographics
NPI:1396094074
Name:ORAL AN IMPLANT SURGERY SPECIALISTS, PC
Entity type:Organization
Organization Name:ORAL AN IMPLANT SURGERY SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DURWOOD
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-461-2101
Mailing Address - Street 1:1260 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4514
Mailing Address - Country:US
Mailing Address - Phone:770-461-2101
Mailing Address - Fax:770-460-1292
Practice Address - Street 1:1260 HIGHWAY 54 W
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4514
Practice Address - Country:US
Practice Address - Phone:770-461-2101
Practice Address - Fax:770-460-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007973204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000189351BMedicaid
GAU22627Medicare UPIN
GA19NCCGCMedicare PIN