Provider Demographics
NPI:1417394958
Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Other - Org Name:DENTAL CARE OF CLAYTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8468
Mailing Address - Street 1:436 WARWOMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-5105
Mailing Address - Country:US
Mailing Address - Phone:706-782-5414
Mailing Address - Fax:
Practice Address - Street 1:436 WARWOMAN RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-5105
Practice Address - Country:US
Practice Address - Phone:706-782-5414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-23
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty