Provider Demographics
NPI:1497857411
Name:ADVANCE FAMILY DENTAL CARE INC
Entity Type:Organization
Organization Name:ADVANCE FAMILY DENTAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-564-9906
Mailing Address - Street 1:449 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-564-9906
Mailing Address - Fax:770-564-9907
Practice Address - Street 1:449 PLEASANT HILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-564-9906
Practice Address - Fax:770-564-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011621223G0001X
FLDN141231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty