Provider Demographics
NPI:1003023870
Name:COLUMBUS ORAL & MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:COLUMBUS ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCUBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-507-0901
Mailing Address - Street 1:4405 N STADIUM DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1875
Mailing Address - Country:US
Mailing Address - Phone:706-507-0901
Mailing Address - Fax:706-507-0984
Practice Address - Street 1:4405 N STADIUM DR
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1878
Practice Address - Country:US
Practice Address - Phone:706-507-0901
Practice Address - Fax:706-507-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132561223S0112X
GA052372204E00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAIP09476001OtherBCBS OF GA (M) GROUP