Provider Demographics
NPI:1659440311
Name:LESTER DENTAL GROUP LLC
Entity Type:Organization
Organization Name:LESTER DENTAL GROUP LLC
Other - Org Name:JOE N LESTER DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:N
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-922-6655
Mailing Address - Street 1:1217 ROYAL DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5967
Mailing Address - Country:US
Mailing Address - Phone:770-922-6655
Mailing Address - Fax:770-388-0521
Practice Address - Street 1:1217 ROYAL DR SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5967
Practice Address - Country:US
Practice Address - Phone:770-922-6655
Practice Address - Fax:770-388-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0099471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA801628040CMedicaid
GA039132651AMedicaid
GA000287955HMedicaid
GA000900974AMedicaid