Provider Demographics
NPI:1063651511
Name:ROYAL DENTAL GROUP
Entity Type:Organization
Organization Name:ROYAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KATASHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-503-7130
Mailing Address - Street 1:821 DAWSONVILLE HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2634
Mailing Address - Country:US
Mailing Address - Phone:770-503-7130
Mailing Address - Fax:
Practice Address - Street 1:821 DAWSONVILLE HWY STE 150
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2634
Practice Address - Country:US
Practice Address - Phone:770-503-7130
Practice Address - Fax:770-503-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128681223G0001X
GADN0131881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA199726296AMedicaid
GA199726296EMedicaid
GA199726296FMedicaid