Provider Demographics
NPI:1386762037
Name:JAMES PROCTOR DDS PC
Entity type:Organization
Organization Name:JAMES PROCTOR DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-483-6800
Mailing Address - Street 1:2045 HONEY CREEK PKWY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2975
Mailing Address - Country:US
Mailing Address - Phone:770-483-6800
Mailing Address - Fax:
Practice Address - Street 1:2045 HONEY CREEK PKWY SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2975
Practice Address - Country:US
Practice Address - Phone:770-483-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00569357BMedicaid