Provider Demographics
NPI:1508639535
Name:GA SDS III PC
Entity Type:Organization
Organization Name:GA SDS III PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIREC OF CRED AND PROV REL
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:401 CHURCH ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-2214
Mailing Address - Country:US
Mailing Address - Phone:504-638-0303
Mailing Address - Fax:
Practice Address - Street 1:91 W WIEUCA RD NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3248
Practice Address - Country:US
Practice Address - Phone:404-303-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty