Provider Demographics
NPI:1659789170
Name:BLUE OCEAN ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:BLUE OCEAN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:CRABAPPLE ORAL SURGERY & IMPLANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROOLS
Authorized Official - Middle Name:LUC
Authorized Official - Last Name:DESSIEUX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-710-6000
Mailing Address - Street 1:260 RUCKER RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4198
Mailing Address - Country:US
Mailing Address - Phone:678-710-6000
Mailing Address - Fax:678-710-6001
Practice Address - Street 1:260 RUCKER RD
Practice Address - Street 2:SUITE 400
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-4198
Practice Address - Country:US
Practice Address - Phone:678-710-6000
Practice Address - Fax:678-710-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery