Provider Demographics
NPI:1881629392
Name:SOUTHERN ORAL SURGERY PC
Entity Type:Organization
Organization Name:SOUTHERN ORAL SURGERY PC
Other - Org Name:DRS GRUSKIN LUCAS & FERRARA PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:FERRARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-228-1010
Mailing Address - Street 1:614 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-228-1010
Mailing Address - Fax:678-692-0242
Practice Address - Street 1:614 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-228-1010
Practice Address - Fax:678-692-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134161223S0112X
GADN0127611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109984AMedicaid
GA178058507BMedicaid
GA178058507AMedicaid
GA003109984AMedicaid