Provider Demographics
NPI:1417374034
Name:ORAL SURGERY OF GEORGIA LLC
Entity Type:Organization
Organization Name:ORAL SURGERY OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-389-1950
Mailing Address - Street 1:1350 SPRING ST NW
Mailing Address - Street 2:STE 600
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2864
Mailing Address - Country:US
Mailing Address - Phone:404-389-1950
Mailing Address - Fax:
Practice Address - Street 1:5590 ROSWELL RD
Practice Address - Street 2:STE 270
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-1909
Practice Address - Country:US
Practice Address - Phone:404-389-1950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty