Provider Demographics
NPI:1114129343
Name:AMERICAN DENTAL OF LAGRANGE, LLC
Entity Type:Organization
Organization Name:AMERICAN DENTAL OF LAGRANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DMO
Authorized Official - Phone:706-837-0123
Mailing Address - Street 1:P.O BOX 457
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023
Mailing Address - Country:US
Mailing Address - Phone:478-290-7340
Mailing Address - Fax:706-668-5100
Practice Address - Street 1:313 MOOTY BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-837-0123
Practice Address - Fax:706-668-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty