Provider Demographics
NPI:1154723518
Name:VALDOSTA CENTER FOR COSMETIC DENTISTRY, INC
Entity type:Organization
Organization Name:VALDOSTA CENTER FOR COSMETIC DENTISTRY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-242-0825
Mailing Address - Street 1:802 NORTHWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1392
Mailing Address - Country:US
Mailing Address - Phone:229-242-0825
Mailing Address - Fax:229-242-0167
Practice Address - Street 1:802 NORTHWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1392
Practice Address - Country:US
Practice Address - Phone:229-242-0825
Practice Address - Fax:229-242-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0091471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty