Provider Demographics
NPI:1427233311
Name:CVINGTON-CONYERS DENTAL
Entity Type:Organization
Organization Name:CVINGTON-CONYERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-625-7505
Mailing Address - Street 1:3162 ELM ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2461
Mailing Address - Country:US
Mailing Address - Phone:678-625-7505
Mailing Address - Fax:
Practice Address - Street 1:3162 ELM ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2461
Practice Address - Country:US
Practice Address - Phone:678-625-7505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11497122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty