Provider Demographics
NPI:1023234853
Name:CENTRAL GEORGIA ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity type:Organization
Organization Name:CENTRAL GEORGIA ORAL AND MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:478-745-0200
Mailing Address - Street 1:740 FIRST ST.
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6840
Mailing Address - Country:US
Mailing Address - Phone:478-745-0200
Mailing Address - Fax:
Practice Address - Street 1:740 FIRST ST.
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6840
Practice Address - Country:US
Practice Address - Phone:478-745-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6880OtherLICENSE