Provider Demographics
NPI:1598817488
Name:SOUTH HAIRSTON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SOUTH HAIRSTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-294-3600
Mailing Address - Street 1:1234 S HAIRSTON RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2749
Mailing Address - Country:US
Mailing Address - Phone:404-294-3600
Mailing Address - Fax:
Practice Address - Street 1:1234 S HAIRSTON RD
Practice Address - Street 2:SUITE 23
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2749
Practice Address - Country:US
Practice Address - Phone:404-294-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00581215AMedicaid