Provider Demographics
NPI:1740379148
Name:ALBANY ORAL SURGERY ASSOCIATES PC
Entity type:Organization
Organization Name:ALBANY ORAL SURGERY ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:229-883-1018
Mailing Address - Street 1:316 FIFTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701
Mailing Address - Country:US
Mailing Address - Phone:229-883-1018
Mailing Address - Fax:
Practice Address - Street 1:316 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-883-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU16818Medicare UPIN
GA70047619DAMedicare ID - Type Unspecified