Provider Demographics
NPI:1639637622
Name:DENTAL WELLNESS CENTER OF MACON, LLC
Entity Type:Organization
Organization Name:DENTAL WELLNESS CENTER OF MACON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OPERATIONS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-920-5577
Mailing Address - Street 1:PO BOX 60339
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31420-0339
Mailing Address - Country:US
Mailing Address - Phone:912-920-5577
Mailing Address - Fax:912-226-3489
Practice Address - Street 1:236 TOM HILL SR BLVD UNIT 9
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1815
Practice Address - Country:US
Practice Address - Phone:888-885-8492
Practice Address - Fax:912-226-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN010747OtherSTATE LICENSE
GA1497918759OtherNPI