Provider Demographics
NPI:1073083127
Name:PEDIATRIC DENTISTRY OF CENTRAL GEORGIA - MACON LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CENTRAL GEORGIA - MACON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BATTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-333-3636
Mailing Address - Street 1:900 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-0520
Mailing Address - Country:US
Mailing Address - Phone:478-333-3636
Mailing Address - Fax:
Practice Address - Street 1:5437 BOWMAN RD STE 300
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-6575
Practice Address - Country:US
Practice Address - Phone:478-333-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty