Provider Demographics
NPI:1316482052
Name:COWETA DENTISTRY SDA PC
Entity type:Organization
Organization Name:COWETA DENTISTRY SDA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-410-1340
Mailing Address - Street 1:50 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1947
Mailing Address - Country:US
Mailing Address - Phone:770-253-2802
Mailing Address - Fax:770-683-7265
Practice Address - Street 1:50 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1947
Practice Address - Country:US
Practice Address - Phone:770-253-2802
Practice Address - Fax:770-683-7265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty