Provider Demographics
NPI:1093895120
Name:STEELE, C. LAVONT (DDS)
Entity Type:Individual
Prefix:DR
First Name:C. LAVONT
Middle Name:
Last Name:STEELE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MIRRAMONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8213
Mailing Address - Country:US
Mailing Address - Phone:770-592-7000
Mailing Address - Fax:770-517-7403
Practice Address - Street 1:114 MIRRAMONT LAKE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8213
Practice Address - Country:US
Practice Address - Phone:770-592-7000
Practice Address - Fax:770-517-7403
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0092051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00210834CMedicaid