Provider Demographics
NPI:1952363442
Name:ADVANCED ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:ADVANCED ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:EAST COBB ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:770-321-0257
Mailing Address - Street 1:3535 ROSWELL RD
Mailing Address - Street 2:SUITE 27
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8826
Mailing Address - Country:US
Mailing Address - Phone:770-321-0257
Mailing Address - Fax:770-321-0346
Practice Address - Street 1:3535 ROSWELL RD
Practice Address - Street 2:SUITE 27
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8826
Practice Address - Country:US
Practice Address - Phone:770-321-0257
Practice Address - Fax:770-321-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053375204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty