Provider Demographics
NPI:1598811739
Name:ATHENS AREA PEDIATRIC DENTISTRY, P.C.
Entity Type:Organization
Organization Name:ATHENS AREA PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,DMD
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-769-1994
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0032
Mailing Address - Country:US
Mailing Address - Phone:706-769-1994
Mailing Address - Fax:706-769-1997
Practice Address - Street 1:1091 PARK DR
Practice Address - Street 2:STE A
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2014
Practice Address - Country:US
Practice Address - Phone:706-769-1994
Practice Address - Fax:706-769-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-27
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0100041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000300671JMedicaid