Provider Demographics
NPI:1497216980
Name:STATESBORO ORAL AND MAXILLOFACIAL SURGERY, INC.
Entity Type:Organization
Organization Name:STATESBORO ORAL AND MAXILLOFACIAL SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAWHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-764-4495
Mailing Address - Street 1:4463 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9188
Mailing Address - Country:US
Mailing Address - Phone:912-764-4495
Mailing Address - Fax:912-764-3650
Practice Address - Street 1:4463 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-9188
Practice Address - Country:US
Practice Address - Phone:912-764-4495
Practice Address - Fax:912-764-3650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty