Provider Demographics
NPI:1114198108
Name:FOGG/ZAREIE ENTERPRISES INC.
Entity Type:Organization
Organization Name:FOGG/ZAREIE ENTERPRISES INC.
Other - Org Name:ATHENS FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-548-3279
Mailing Address - Street 1:3380 OLD JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1480
Mailing Address - Country:US
Mailing Address - Phone:706-548-3279
Mailing Address - Fax:706-546-6475
Practice Address - Street 1:3380 OLD JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1480
Practice Address - Country:US
Practice Address - Phone:706-548-3279
Practice Address - Fax:706-546-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0068051223G0001X
GA0090001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00176778CMedicaid
GA00862705AMedicaid
GA00915516AMedicaid
GA00508065AMedicaid