1134491657 NPI number — HEARTLAND DENTAL CARE OF GEORGIA, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134491657 NPI number — HEARTLAND DENTAL CARE OF GEORGIA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MYNORTHATLANTADENTIST.COM
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134491657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5252 ROSWELL RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-252-5252
Provider Business Mailing Address Fax Number:
404-252-1676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5252 ROSWELL RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-252-5252
Provider Business Practice Location Address Fax Number:
404-252-1676
Provider Enumeration Date:
01/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE/CREDENTIALING
Authorized Official Telephone Number:
217-540-5100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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