Provider Demographics
NPI:1154682219
Name:LOGANVILLE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:LOGANVILLE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-466-0580
Mailing Address - Street 1:150 HIGHWAY 78
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2277
Mailing Address - Country:US
Mailing Address - Phone:770-466-0580
Mailing Address - Fax:
Practice Address - Street 1:150 HIGHWAY 78
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2277
Practice Address - Country:US
Practice Address - Phone:770-466-0580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty