Provider Demographics
NPI:1528422524
Name:GOVERNMENT DENTAL LLC
Entity type:Organization
Organization Name:GOVERNMENT DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:WEATHERSPOON
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-256-2638
Mailing Address - Street 1:7218 HIGHWAY 85
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2908
Mailing Address - Country:US
Mailing Address - Phone:404-593-3404
Mailing Address - Fax:
Practice Address - Street 1:7218 HIGHWAY 85
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2908
Practice Address - Country:US
Practice Address - Phone:404-593-3404
Practice Address - Fax:404-228-9673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14566GA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003180284AMedicaid