Provider Demographics
NPI:1093578718
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:952 HARBINS RD
Mailing Address - Street 2:STE 401
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2824
Mailing Address - Country:US
Mailing Address - Phone:470-268-3056
Mailing Address - Fax:470-268-3127
Practice Address - Street 1:952 HARBINS RD
Practice Address - Street 2:STE 401
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2824
Practice Address - Country:US
Practice Address - Phone:470-268-3056
Practice Address - Fax:470-268-3127
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty