Provider Demographics
NPI:1972800175
Name:W. MAX COUCH, JR., DDS, MDS, LLC
Entity Type:Organization
Organization Name:W. MAX COUCH, JR., DDS, MDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:770-833-9150
Mailing Address - Street 1:2714 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513
Mailing Address - Country:US
Mailing Address - Phone:770-833-9150
Mailing Address - Fax:706-946-2672
Practice Address - Street 1:2714 EAST FIRST STREET
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513
Practice Address - Country:US
Practice Address - Phone:770-833-9150
Practice Address - Fax:706-946-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0118951223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty