Provider Demographics
NPI:1912173022
Name:VALDOSTA ORAL AND MAXILLOFACIAL SURGEONS
Entity Type:Organization
Organization Name:VALDOSTA ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-247-5590
Mailing Address - Street 1:2720 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1781
Mailing Address - Country:US
Mailing Address - Phone:229-247-5590
Mailing Address - Fax:229-241-0698
Practice Address - Street 1:2720 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1781
Practice Address - Country:US
Practice Address - Phone:229-247-5590
Practice Address - Fax:229-241-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0082191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6639OtherMEDICARE GROUP NUMBER
U22620Medicare UPIN