Provider Demographics
NPI:1811948771
Name:SCUBA, JOHN RICHARD (MD, DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:SCUBA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 CHAMPIONS WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2075
Mailing Address - Country:US
Mailing Address - Phone:706-561-5879
Mailing Address - Fax:
Practice Address - Street 1:COLUMBUS ORAL & MAXILLOFACIAL SURGERY
Practice Address - Street 2:4405 N. STADIUM DRIVE, SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:706-507-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0132561223S0112X
GA052372204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery