Provider Demographics
NPI:1063904076
Name:NORTHEAST GEORGIA DENTAL GROUP
Entity type:Organization
Organization Name:NORTHEAST GEORGIA DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-532-4555
Mailing Address - Street 1:1215 VINE ST NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2535
Mailing Address - Country:US
Mailing Address - Phone:770-532-4555
Mailing Address - Fax:770-536-8053
Practice Address - Street 1:1205 FRIENDSHIP ROAD
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:770-532-4555
Practice Address - Fax:770-536-8053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty