Provider Demographics
NPI:1003233107
Name:HEARTLAND DENTAL CARE OF GEORGIA
Entity Type:Organization
Organization Name:HEARTLAND DENTAL CARE OF GEORGIA
Other - Org Name:FAMILY DENTAL OF CANTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8329
Mailing Address - Street 1:3237 SIXES RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-450-1689
Mailing Address - Fax:
Practice Address - Street 1:3237 SIXES RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-450-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL CARE OF GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty