Provider Demographics
NPI:1194972901
Name:NORTH GEORGIA DENTAL SEDATION CENTER
Entity type:Organization
Organization Name:NORTH GEORGIA DENTAL SEDATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-714-7011
Mailing Address - Street 1:655 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3756
Mailing Address - Country:US
Mailing Address - Phone:770-539-9110
Mailing Address - Fax:678-714-8388
Practice Address - Street 1:655 JESSE JEWEL PKWY SE
Practice Address - Street 2:SUITE E
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-539-9110
Practice Address - Fax:678-714-8388
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDRENS DENTISTRY AT GAINESVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0120821223P0221X
GADN0134431223P0221X
GADN0080321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000046582YMedicaid
GA500132139CMedicaid
GA000851727BMedicaid