Provider Demographics
NPI:1649843301
Name:ORAL MAXILLOFACIAL SURGERY GROUP OF COASTAL GEORGIA
Entity type:Organization
Organization Name:ORAL MAXILLOFACIAL SURGERY GROUP OF COASTAL GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:THEODOTOU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-600-6060
Mailing Address - Street 1:506 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2104
Mailing Address - Country:US
Mailing Address - Phone:912-600-6060
Mailing Address - Fax:
Practice Address - Street 1:506 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2104
Practice Address - Country:US
Practice Address - Phone:912-600-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty