Provider Demographics
NPI:1497263909
Name:PEACH DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:PEACH DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-535-8900
Mailing Address - Street 1:819 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78 DAWSON VILLAGE WAY N STE 170
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-5643
Practice Address - Country:US
Practice Address - Phone:407-340-4304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty