Provider Demographics
NPI:1215315312
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:CRED SUP
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:3983 LAVISTA RD STE 104
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5140
Mailing Address - Country:US
Mailing Address - Phone:770-723-1111
Mailing Address - Fax:
Practice Address - Street 1:3983 LAVISTA RD STE 104
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5140
Practice Address - Country:US
Practice Address - Phone:770-723-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty