Provider Demographics
NPI:1104218361
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:ELITE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUP
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:3052 SHALLOWFORD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1252
Mailing Address - Country:US
Mailing Address - Phone:770-587-5655
Mailing Address - Fax:
Practice Address - Street 1:3052 SHALLOWFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-1252
Practice Address - Country:US
Practice Address - Phone:770-587-5655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty