Provider Demographics
NPI:1306159926
Name:GEORGIA DENTAL CLINIC, P.C.
Entity type:Organization
Organization Name:GEORGIA DENTAL CLINIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-998-5290
Mailing Address - Street 1:2860 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8339
Mailing Address - Country:US
Mailing Address - Phone:770-998-5290
Mailing Address - Fax:770-552-4795
Practice Address - Street 1:2860 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8339
Practice Address - Country:US
Practice Address - Phone:770-998-5290
Practice Address - Fax:770-552-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-24
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADL0137561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty