1417174723 NPI number — MIDDLE GEORGIA FAMILY DENTISTRY

Table of content: (NPI 1417174723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417174723 NPI number — MIDDLE GEORGIA FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDDLE GEORGIA FAMILY DENTISTRY
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:
1417174723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 BELLEVUE RD STE 28
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-2874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-272-1933
Provider Business Mailing Address Fax Number:
478-275-7973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 BELLEVUE RD STE 28
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-2874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-1933
Provider Business Practice Location Address Fax Number:
478-275-7973
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
LEE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
478-272-1933

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  11329 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 012354 , 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)





Copyright © 2007-2025 www.npivalidator.com