Provider Demographics
NPI:1285745505
Name:WOOD, ANDREA DAVIS (DMD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAVIS
Last Name:WOOD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 BOAT ROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7316
Mailing Address - Country:US
Mailing Address - Phone:404-310-6548
Mailing Address - Fax:
Practice Address - Street 1:1536 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3130
Practice Address - Country:US
Practice Address - Phone:478-781-4333
Practice Address - Fax:478-781-4331
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0110291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000471875Medicaid
GA1429244OtherUNITED CONCORDIA
GA100759OtherAVESIS
GA9180606OtherDENTAQUEST