Provider Demographics
NPI:1528412707
Name:BULLARD DENTAL
Entity Type:Organization
Organization Name:BULLARD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:706-863-5337
Mailing Address - Street 1:3702 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2848
Mailing Address - Country:US
Mailing Address - Phone:706-863-5337
Mailing Address - Fax:706-855-8249
Practice Address - Street 1:3702 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2848
Practice Address - Country:US
Practice Address - Phone:706-863-5337
Practice Address - Fax:706-855-8249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty