Provider Demographics
NPI:1639426836
Name:QUITMAN FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:QUITMAN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-263-8700
Mailing Address - Street 1:1306 E. SCREVEN STREET
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31634
Mailing Address - Country:US
Mailing Address - Phone:229-263-8700
Mailing Address - Fax:
Practice Address - Street 1:1306 E. SCREVEN STREET
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31634
Practice Address - Country:US
Practice Address - Phone:229-263-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012932261QD0000X
GADNSC000233261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124373AMedicaid