Provider Demographics
NPI:1154555282
Name:ORTHODONTIC CARE OF GEORGIA
Entity type:Organization
Organization Name:ORTHODONTIC CARE OF GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-342-7272
Mailing Address - Street 1:1828 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5960
Mailing Address - Country:US
Mailing Address - Phone:678-432-8505
Mailing Address - Fax:678-432-9419
Practice Address - Street 1:1690 EATONTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-4628
Practice Address - Country:US
Practice Address - Phone:706-342-7272
Practice Address - Fax:706-342-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0113091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty