Provider Demographics
NPI:1700234168
Name:WOMBLE, BRIAN A (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN A
Middle Name:
Last Name:WOMBLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:235 EAGLES LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4221
Mailing Address - Country:US
Mailing Address - Phone:770-914-2808
Mailing Address - Fax:678-432-9193
Practice Address - Street 1:420 MCDONOUGH PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8946
Practice Address - Country:US
Practice Address - Phone:770-914-2808
Practice Address - Fax:678-432-9193
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA92131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics