Provider Demographics
NPI:1760775043
Name:G. MICHAEL WOMMACK, DMD, PC
Entity Type:Organization
Organization Name:G. MICHAEL WOMMACK, DMD, PC
Other - Org Name:WOMMACK DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-342-7049
Mailing Address - Street 1:2900 GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4844
Mailing Address - Country:US
Mailing Address - Phone:912-342-7049
Mailing Address - Fax:912-342-7942
Practice Address - Street 1:2900 GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4844
Practice Address - Country:US
Practice Address - Phone:912-342-7049
Practice Address - Fax:912-342-7942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty