1215487467 NPI number — GORDON HIGHWAY DENTAL GROUP, LLC

Table of content: (NPI 1215487467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215487467 NPI number — GORDON HIGHWAY DENTAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON HIGHWAY DENTAL GROUP, LLC
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:
1215487467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 CHURCH ST STE 2210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37219-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-988-2627
Provider Business Mailing Address Fax Number:
631-857-7860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1631 GORDON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-790-9302
Provider Business Practice Location Address Fax Number:
706-790-9303
Provider Enumeration Date:
10/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ZOELLER
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
SUSAN
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-988-2627

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN015152 , 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)





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