Provider Demographics
NPI:1538112016
Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:H
Authorized Official - Last Name:O'NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-724-8735
Mailing Address - Street 1:7011 EVANS TOWN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4315
Mailing Address - Country:US
Mailing Address - Phone:706-724-8735
Mailing Address - Fax:706-722-7037
Practice Address - Street 1:7011 EVANS TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4315
Practice Address - Country:US
Practice Address - Phone:706-724-8735
Practice Address - Fax:706-722-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300020478AMedicaid
SCZAG985Medicaid
GA300020478AMedicaid