Provider Demographics
NPI:1235635715
Name:WINTERVILLE DENTAL, LLC
Entity Type:Organization
Organization Name:WINTERVILLE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:HUE
Authorized Official - Last Name:DURDEN
Authorized Official - Suffix:IV
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-742-7000
Mailing Address - Street 1:104 MOORES GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-1506
Mailing Address - Country:US
Mailing Address - Phone:706-742-7000
Mailing Address - Fax:706-742-2145
Practice Address - Street 1:104 MOORES GROVE RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30683-1506
Practice Address - Country:US
Practice Address - Phone:706-742-7000
Practice Address - Fax:706-742-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental