Provider Demographics
NPI:1407699739
Name:ATHENS GPR LLC
Entity type:Organization
Organization Name:ATHENS GPR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-726-3397
Mailing Address - Street 1:PO BOX 7501
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7501
Mailing Address - Country:US
Mailing Address - Phone:706-715-0267
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY STE 101
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7300
Practice Address - Country:US
Practice Address - Phone:706-543-3629
Practice Address - Fax:706-543-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty