1003233107 NPI number — HEARTLAND DENTAL CARE OF GEORGIA

Table of content: MRS. CANDACE RAINELLE RAW RNFA (NPI 1346347762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003233107 NPI number — HEARTLAND DENTAL CARE OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND DENTAL CARE 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:
6
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:
1003233107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3237 SIXES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-450-1689
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3237 SIXES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-450-1689
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CORNELL
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
217-540-8329

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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