Provider Demographics
NPI:1396882783
Name:ALLRED DENTAL GROUP LLC
Entity type:Organization
Organization Name:ALLRED DENTAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-741-8433
Mailing Address - Street 1:743 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4818
Mailing Address - Country:US
Mailing Address - Phone:770-228-6101
Mailing Address - Fax:770-228-6170
Practice Address - Street 1:743 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4818
Practice Address - Country:US
Practice Address - Phone:770-228-6101
Practice Address - Fax:770-228-6170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010469302R00000X
GA014094302R00000X
GA014960302R00000X
GA014067302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340647560AMedicaid
GA877225484AMedicaid
GA003162738CMedicaid
GA00727097AMedicaid