1760870885 NPI number — SPECIAL CARE DENTAL OF GEORGIA

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 1760870885 NPI number — SPECIAL CARE DENTAL OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIAL CARE DENTAL OF GEORGIA
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:
Provider Other Organization Name Type Code:
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:
1760870885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12910 SHELBYVILLE RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40243-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-244-2441
Provider Business Mailing Address Fax Number:
502-254-4086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 JOHN MADDOX DR NW
Provider Second Line Business Practice Location Address:
STE. 128
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30165-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-259-9183
Provider Business Practice Location Address Fax Number:
502-254-4086
Provider Enumeration Date:
12/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ELLINGTON
Authorized Official First Name:
KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
855-259-9183

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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