Provider Demographics
NPI:1275634487
Name:PARKSIDE DENTAL PRACTICE
Entity Type:Organization
Organization Name:PARKSIDE DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATLAGA DDS GEN PTR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-487-8882
Mailing Address - Street 1:410 STEVENS ENTRY
Mailing Address - Street 2:PO BOX 2606
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:770-487-8882
Mailing Address - Fax:770-486-9469
Practice Address - Street 1:410 STEVENS ENTRY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:770-487-8882
Practice Address - Fax:770-486-9469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA8697251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTIN