Provider Demographics
NPI:1215573845
Name:HOMETOWN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:HOMETOWN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:AMOS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:706-387-0305
Mailing Address - Street 1:1363 OLD PENDERGRASS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2790
Mailing Address - Country:US
Mailing Address - Phone:706-387-0305
Mailing Address - Fax:706-708-2253
Practice Address - Street 1:1363 OLD PENDERGRASS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2790
Practice Address - Country:US
Practice Address - Phone:706-387-0305
Practice Address - Fax:706-708-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental