Provider Demographics
NPI:1457606881
Name:MACON PERIODONTICS AND IMPLANT DENTISTRY, LLC
Entity type:Organization
Organization Name:MACON PERIODONTICS AND IMPLANT DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-742-4254
Mailing Address - Street 1:1923 HARDEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1162
Mailing Address - Country:US
Mailing Address - Phone:478-742-4254
Mailing Address - Fax:478-742-1457
Practice Address - Street 1:1923 HARDEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1162
Practice Address - Country:US
Practice Address - Phone:478-742-4254
Practice Address - Fax:478-742-1457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty