Provider Demographics
NPI:1033250972
Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Entity Type:Organization
Organization Name:GEORGIA DEPARTMENT OF HUMAN RESOURCES
Other - Org Name:FLOYD COUNTY REGIONAL DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-295-6704
Mailing Address - Street 1:1309 REDMOND RD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1307
Mailing Address - Country:US
Mailing Address - Phone:706-802-5343
Mailing Address - Fax:706-802-5681
Practice Address - Street 1:16 E 12TH ST SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4720
Practice Address - Country:US
Practice Address - Phone:706-802-5343
Practice Address - Fax:706-802-5681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025271261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000926879EMedicaid
GA000926879IMedicaid
GA000926879BMedicaid
GA000926879HMedicaid
GA000926879Medicaid
GA000926879AMedicaid
GA000926879FMedicaid
GA000926879GMedicaid
GA0009288679BMedicaid
GA000926879DMedicaid