Provider Demographics
NPI:1275898900
Name:DYESS PARKWAY DENTAL, LLC
Entity Type:Organization
Organization Name:DYESS PARKWAY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANNAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-868-4200
Mailing Address - Street 1:4045 JIMMIE DYESS PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9492
Mailing Address - Country:US
Mailing Address - Phone:706-868-4200
Mailing Address - Fax:706-868-4717
Practice Address - Street 1:4045 JIMMIE DYESS PKWY STE 103
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9492
Practice Address - Country:US
Practice Address - Phone:706-868-4200
Practice Address - Fax:706-868-4717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty