Provider Demographics
NPI:1477859387
Name:SWEETGUMS DENTAL LLC
Entity Type:Organization
Organization Name:SWEETGUMS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LARETHA
Authorized Official - Middle Name:URETT
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-507-9132
Mailing Address - Street 1:1435 54TH ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4998
Mailing Address - Country:US
Mailing Address - Phone:706-507-9132
Mailing Address - Fax:706-507-9135
Practice Address - Street 1:1435 54TH ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4998
Practice Address - Country:US
Practice Address - Phone:706-507-9132
Practice Address - Fax:706-507-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA355358613BMedicaid