Provider Demographics
NPI:1235674227
Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Other - Org Name:CALUMET FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:116 CALUMET CENTER RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-6703
Mailing Address - Country:US
Mailing Address - Phone:706-882-2937
Mailing Address - Fax:
Practice Address - Street 1:116 CALUMET CENTER RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-6703
Practice Address - Country:US
Practice Address - Phone:706-882-2937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty