Provider Demographics
NPI:1104843861
Name:DENTAL ASSOCIATES OF SOUTHWEST GEORGIA, LLC
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF SOUTHWEST GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEGGETT JR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-377-4204
Mailing Address - Street 1:718 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-1607
Mailing Address - Country:US
Mailing Address - Phone:229-377-4204
Mailing Address - Fax:229-377-7753
Practice Address - Street 1:718 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-1607
Practice Address - Country:US
Practice Address - Phone:229-377-4204
Practice Address - Fax:229-377-7753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty