Provider Demographics
NPI:1215313044
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-217-4952
Mailing Address - Street 1:6005 WATSON BLVD SUITE 200
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6005 WATSON BLVD SUITE 200
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008
Practice Address - Country:US
Practice Address - Phone:478-217-4952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty