Provider Demographics
NPI:1619019874
Name:ATLANTA ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:ATLANTA ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOETSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:770-729-1481
Mailing Address - Street 1:3875 HOLCOMB BRIDGE RD
Mailing Address - Street 2:STE 4
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2269
Mailing Address - Country:US
Mailing Address - Phone:770-729-1481
Mailing Address - Fax:770-448-2225
Practice Address - Street 1:3875 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE 4
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2269
Practice Address - Country:US
Practice Address - Phone:770-729-1481
Practice Address - Fax:770-448-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0109071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA667702OtherUNITED CONCORDIA