Provider Demographics
NPI:1386795805
Name:SOUTH DEKALB DENTAL CENTER LLC
Entity type:Organization
Organization Name:SOUTH DEKALB DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:LITTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-879-1177
Mailing Address - Street 1:2853 CANDLER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1433
Mailing Address - Country:US
Mailing Address - Phone:404-244-1166
Mailing Address - Fax:
Practice Address - Street 1:2853 CANDLER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1433
Practice Address - Country:US
Practice Address - Phone:404-244-1166
Practice Address - Fax:404-244-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service