Provider Demographics
NPI:1316397037
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:MULBERRY CREEK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:4030 WINDER HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542
Mailing Address - Country:US
Mailing Address - Phone:678-217-8591
Mailing Address - Fax:
Practice Address - Street 1:4030 WINDER HIGHWAY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542
Practice Address - Country:US
Practice Address - Phone:678-217-8591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-14
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty