Provider Demographics
NPI:1437297959
Name:AMERICAN DENTAL GROUP-GEORGIA LLC
Entity Type:Organization
Organization Name:AMERICAN DENTAL GROUP-GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RIVARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-203-1119
Mailing Address - Street 1:300 E LONG LAKE RD
Mailing Address - Street 2:STE 311
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2374
Mailing Address - Country:US
Mailing Address - Phone:248-203-1100
Mailing Address - Fax:
Practice Address - Street 1:300 E LONG LAKE RD
Practice Address - Street 2:STE 311
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2374
Practice Address - Country:US
Practice Address - Phone:248-203-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty