Provider Demographics
NPI:1558562074
Name:FAMILY PRACTICE DENTAL CARE OF STATESBORO
Entity Type:Organization
Organization Name:FAMILY PRACTICE DENTAL CARE OF STATESBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:CYRIL
Authorized Official - Last Name:MADSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-764-9187
Mailing Address - Street 1:1046 NORTHSIDE DR E
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1002
Mailing Address - Country:US
Mailing Address - Phone:912-764-9187
Mailing Address - Fax:912-764-7530
Practice Address - Street 1:1046 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1002
Practice Address - Country:US
Practice Address - Phone:912-764-9187
Practice Address - Fax:912-764-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty