1063028769 NPI number — GEORGIA DENTAL PROFESSIONALS, PC

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 1063028769 NPI number — GEORGIA DENTAL PROFESSIONALS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA DENTAL PROFESSIONALS, PC
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:
1063028769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3364 HAMILTON MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30519-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-326-6929
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3364 HAMILTON MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30519-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-326-6929
Provider Business Practice Location Address Fax Number:
770-686-3976
Provider Enumeration Date:
09/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BRITT
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
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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