Provider Demographics
NPI:1093283715
Name:NORTHEAST GEORGIA DENTAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA DENTAL PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-932-4240
Mailing Address - Street 1:2700 BRASELTON HWY STE 12
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-3263
Mailing Address - Country:US
Mailing Address - Phone:770-932-4240
Mailing Address - Fax:
Practice Address - Street 1:2700 BRASELTON HWY STE 12
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-3263
Practice Address - Country:US
Practice Address - Phone:770-932-4240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty