Provider Demographics
NPI:1336211234
Name:HAWKINSVILLE DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:HAWKINSVILLE DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:CHEEK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-783-3390
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-0816
Mailing Address - Country:US
Mailing Address - Phone:478-783-3390
Mailing Address - Fax:478-783-3381
Practice Address - Street 1:ROUTE 4 BOX 7085
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036
Practice Address - Country:US
Practice Address - Phone:478-783-3390
Practice Address - Fax:478-783-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA011191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty