Provider Demographics
NPI:1285411694
Name:GEORGIA DENTAL AFFILIATES, LLC
Entity type:Organization
Organization Name:GEORGIA DENTAL AFFILIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-634-6600
Mailing Address - Street 1:110 OFFICE PARK LN STE 104
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-6604
Mailing Address - Country:US
Mailing Address - Phone:912-634-6600
Mailing Address - Fax:
Practice Address - Street 1:110 OFFICE PARK LN STE 104
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-6604
Practice Address - Country:US
Practice Address - Phone:912-634-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty