Provider Demographics
NPI:1356834360
Name:COVINGTON DENTAL CARE
Entity Type:Organization
Organization Name:COVINGTON DENTAL CARE
Other - Org Name:EAST METRO BEAUTIFUL SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-787-1013
Mailing Address - Street 1:4139 BAKER STREET,
Mailing Address - Street 2:SUITE 15
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:770-787-1013
Mailing Address - Fax:770-787-1018
Practice Address - Street 1:4139 BAKER STREET
Practice Address - Street 2:SUITE 15
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-787-1013
Practice Address - Fax:770-787-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000952465ABCDMedicaid