Provider Demographics
NPI:1962876532
Name:DENTAL CENTER OF CARROLLTON
Entity type:Organization
Organization Name:DENTAL CENTER OF CARROLLTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:S
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-834-9682
Mailing Address - Street 1:409 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3921
Mailing Address - Country:US
Mailing Address - Phone:770-834-9682
Mailing Address - Fax:770-836-0622
Practice Address - Street 1:409 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3921
Practice Address - Country:US
Practice Address - Phone:770-834-9682
Practice Address - Fax:770-836-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010873335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7440360001Medicare NSC