Provider Demographics
NPI:1417782707
Name:MDG - MCDONOUGH DENTAL LLC
Entity type:Organization
Organization Name:MDG - MCDONOUGH DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KELLEN
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-358-8175
Mailing Address - Street 1:97 ATLANTA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2192
Mailing Address - Country:US
Mailing Address - Phone:770-954-7780
Mailing Address - Fax:770-954-1640
Practice Address - Street 1:97 ATLANTA ST STE 200
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-2192
Practice Address - Country:US
Practice Address - Phone:770-954-7780
Practice Address - Fax:770-954-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty