Provider Demographics
NPI:1154681195
Name:LAKE OCONEE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:LAKE OCONEE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-454-1500
Mailing Address - Street 1:1031 FOUNDERS ROW
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642
Mailing Address - Country:US
Mailing Address - Phone:706-454-1500
Mailing Address - Fax:706-454-1501
Practice Address - Street 1:1031 FOUNDERS ROW
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642
Practice Address - Country:US
Practice Address - Phone:706-454-1500
Practice Address - Fax:706-454-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty