Provider Demographics
NPI:1164634440
Name:MABLETON DENTAL INC
Entity Type:Organization
Organization Name:MABLETON DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLLIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-944-8700
Mailing Address - Street 1:PO BOX 1159
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:770-944-8700
Mailing Address - Fax:770-819-1190
Practice Address - Street 1:5841 MABLETON PKWY
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:770-944-8700
Practice Address - Fax:770-819-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty