1861767253 NPI number — WEST GEORGIA DENTISTRY FOR CHILDREN

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 1861767253 NPI number — WEST GEORGIA DENTISTRY FOR CHILDREN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST GEORGIA DENTISTRY FOR CHILDREN
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:
1861767253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3827 JIMMY LEE SMITH PKWY
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
HIRAM
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30141-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-384-1787
Provider Business Mailing Address Fax Number:
678-384-1459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3827 JIMMY LEE SMITH PKWY
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
HIRAM
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30141-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-384-1787
Provider Business Practice Location Address Fax Number:
678-384-1459
Provider Enumeration Date:
03/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BINGHAM-SHULTZ
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
678-384-1787

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  06110450 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 156788755 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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