Provider Demographics
NPI:1407122799
Name:HEARTLAND DENTAL CARE OF GEORGIA
Entity Type:Organization
Organization Name:HEARTLAND DENTAL CARE OF GEORGIA
Other - Org Name:CLAIRMONT DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:290 HIGHWAY 314 STE A
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7813
Mailing Address - Country:US
Mailing Address - Phone:770-460-6060
Mailing Address - Fax:770-461-0541
Practice Address - Street 1:290 HIGHWAY 314 STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7813
Practice Address - Country:US
Practice Address - Phone:770-460-6060
Practice Address - Fax:770-461-0541
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL CARE OF GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty