Provider Demographics
NPI:1619516002
Name:GEORGIA DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GEORGIA DENTAL ASSOCIATES, LLC
Other - Org Name:GEORGIA DENTAL ASSOCIATES OF TIFTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NETTIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-848-2685
Mailing Address - Street 1:315 14TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4018
Mailing Address - Country:US
Mailing Address - Phone:229-313-5083
Mailing Address - Fax:
Practice Address - Street 1:315 14TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4018
Practice Address - Country:US
Practice Address - Phone:229-313-5083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-02
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental