Provider Demographics
NPI:1295189595
Name:PROVIDENCE DENTAL LLC
Entity Type:Organization
Organization Name:PROVIDENCE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-733-0857
Mailing Address - Street 1:225 N MACON ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-6562
Mailing Address - Country:US
Mailing Address - Phone:478-733-0857
Mailing Address - Fax:478-254-5709
Practice Address - Street 1:225 N MACON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-6562
Practice Address - Country:US
Practice Address - Phone:478-733-0857
Practice Address - Fax:478-254-5709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty