Provider Demographics
NPI:1326258351
Name:COOSA DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:COOSA DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:GANDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-748-7736
Mailing Address - Street 1:109 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2921
Mailing Address - Country:US
Mailing Address - Phone:770-748-7736
Mailing Address - Fax:770-748-4015
Practice Address - Street 1:109 EAST AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2921
Practice Address - Country:US
Practice Address - Phone:770-748-7736
Practice Address - Fax:770-748-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0104471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty