Provider Demographics
NPI:1942862859
Name:MIDDLE GEORGIA ORAL AND MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA ORAL AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SMALLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-340-3408
Mailing Address - Street 1:401 CREST DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5525
Mailing Address - Country:US
Mailing Address - Phone:478-290-7275
Mailing Address - Fax:
Practice Address - Street 1:117 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5245
Practice Address - Country:US
Practice Address - Phone:706-340-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN014148OtherSTATE LICENSE