Provider Demographics
NPI:1982722013
Name:ORAL SURGERY GROUP OF COASTAL GEORGIA, LLC
Entity type:Organization
Organization Name:ORAL SURGERY GROUP OF COASTAL GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:502-254-8500
Mailing Address - Street 1:506 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2104
Mailing Address - Country:US
Mailing Address - Phone:912-330-9229
Mailing Address - Fax:
Practice Address - Street 1:506 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-330-9229
Practice Address - Fax:912-330-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty