Provider Demographics
NPI:1306280458
Name:MID AMERICA GROUP OF GEORGIA PC
Entity type:Organization
Organization Name:MID AMERICA GROUP OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEWEL
Authorized Official - Middle Name:BERNADETTE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-886-6639
Mailing Address - Street 1:1499 WINDHORST WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8800
Mailing Address - Country:US
Mailing Address - Phone:317-886-6639
Mailing Address - Fax:888-547-0377
Practice Address - Street 1:160 CLAIREMONT AVE
Practice Address - Street 2:STE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2546
Practice Address - Country:US
Practice Address - Phone:317-886-6637
Practice Address - Fax:888-547-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty