Provider Demographics
NPI:1659606408
Name:DALTON PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:DALTON PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-226-3311
Mailing Address - Street 1:1501 BROADRICK DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-226-3311
Mailing Address - Fax:706-275-8723
Practice Address - Street 1:1501 BROADRICK DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-226-3311
Practice Address - Fax:706-275-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023677208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00245627AMedicaid
GA00245627AMedicaid