Provider Demographics
NPI:1811168909
Name:GREGORY M THACKSTON, DMD,MAGD,LLC
Entity type:Organization
Organization Name:GREGORY M THACKSTON, DMD,MAGD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-7200
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1150
Mailing Address - Country:US
Mailing Address - Phone:912-384-7200
Mailing Address - Fax:912-384-0885
Practice Address - Street 1:506 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4616
Practice Address - Country:US
Practice Address - Phone:912-384-7200
Practice Address - Fax:912-384-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA98881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty