Provider Demographics
NPI:1720300791
Name:WILLIAM J POTTORF DDS PC
Entity type:Organization
Organization Name:WILLIAM J POTTORF DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECTY
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:DARLEEN
Authorized Official - Last Name:POTTORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-7709
Mailing Address - Street 1:406 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3922
Mailing Address - Country:US
Mailing Address - Phone:770-834-7709
Mailing Address - Fax:770-836-9020
Practice Address - Street 1:406 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3922
Practice Address - Country:US
Practice Address - Phone:770-834-7709
Practice Address - Fax:770-836-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839004OtherUNITED CONCORDIA