Provider Demographics
NPI:1164640801
Name:MH DENTAL PC
Entity Type:Organization
Organization Name:MH DENTAL PC
Other - Org Name:VITAL SMILES GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COLLECTIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-367-8389
Mailing Address - Street 1:1030A WEST GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701
Mailing Address - Country:US
Mailing Address - Phone:770-248-9029
Mailing Address - Fax:770-248-9130
Practice Address - Street 1:6000 SINGLETON RD
Practice Address - Street 2:STE 315
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:770-248-9029
Practice Address - Fax:770-248-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA714338776BMedicaid