Provider Demographics
NPI:1487807434
Name:LAGRANGE FAMILY DENTAL CENTER
Entity type:Organization
Organization Name:LAGRANGE FAMILY DENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-882-5551
Mailing Address - Street 1:PO BOX 2030
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-0042
Mailing Address - Country:US
Mailing Address - Phone:706-882-5551
Mailing Address - Fax:706-812-8558
Practice Address - Street 1:606 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3128
Practice Address - Country:US
Practice Address - Phone:706-882-5551
Practice Address - Fax:706-812-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1669413993Medicaid
GA1386680734Medicaid