Provider Demographics
NPI:1164289377
Name:ATLANTA ORAL & FACIAL SURGERY LLC
Entity Type:Organization
Organization Name:ATLANTA ORAL & FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-356-0489
Mailing Address - Street 1:121 MARBLE MILL RD NW STE 203
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7959
Mailing Address - Country:US
Mailing Address - Phone:770-356-0489
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD BLDG H
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5518
Practice Address - Country:US
Practice Address - Phone:770-977-0364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTA ORAL & FACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty