Provider Demographics
NPI:1053444547
Name:BULLOCH-PATTERSON, ANGELA (DMD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BULLOCH-PATTERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PARKER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-6436
Mailing Address - Country:US
Mailing Address - Phone:706-298-5007
Mailing Address - Fax:706-298-5008
Practice Address - Street 1:202 CALUMET CENTER RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-6712
Practice Address - Country:US
Practice Address - Phone:706-298-0007
Practice Address - Fax:706-298-5008
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012736122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA588361758AMedicaid
AZ790594Medicaid