Provider Demographics
NPI:1992977243
Name:SOUTHERN GEORGIA ORAL SURGERY
Entity type:Organization
Organization Name:SOUTHERN GEORGIA ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-975-0197
Mailing Address - Street 1:790 FRANK COCHRAN DR STE 102
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3991
Mailing Address - Country:US
Mailing Address - Phone:267-975-0197
Mailing Address - Fax:
Practice Address - Street 1:790 FRANK COCHRAN DR STE 102
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3991
Practice Address - Country:US
Practice Address - Phone:267-975-0197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty