Provider Demographics
NPI:1003040163
Name:ORTHODONTIC CARE OF GEORGIA
Entity Type:Organization
Organization Name:ORTHODONTIC CARE OF GEORGIA
Other - Org Name:DR. HECTOR M. BUSH, P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-342-7272
Mailing Address - Street 1:1828 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5960
Mailing Address - Country:US
Mailing Address - Phone:678-432-8505
Mailing Address - Fax:678-432-9419
Practice Address - Street 1:1109 S PARK ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4462
Practice Address - Country:US
Practice Address - Phone:678-796-0511
Practice Address - Fax:678-796-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0113091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty