Provider Demographics
NPI:1689479248
Name:EASTGATE ORAL SURGERY AND IMPLANTS
Entity type:Organization
Organization Name:EASTGATE ORAL SURGERY AND IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCLAURIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-259-6739
Mailing Address - Street 1:4452 EASTGATE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1584
Mailing Address - Country:US
Mailing Address - Phone:513-643-3192
Mailing Address - Fax:
Practice Address - Street 1:4452 EASTGATE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1584
Practice Address - Country:US
Practice Address - Phone:513-643-3192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty