1083074868 NPI number — MACON DENTIST OFFICE, 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 1083074868 NPI number — MACON DENTIST OFFICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACON DENTIST OFFICE, 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:
1083074868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 RED HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
949-474-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 TOM HILL SR BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-654-3111
Provider Business Practice Location Address Fax Number:
478-246-0074
Provider Enumeration Date:
03/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MCCANN
Authorized Official First Name:
KATIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-654-3111

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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