Provider Demographics
NPI:1679231831
Name:PROVIDENCE DENTAL SPA OF NEWNAN, LLC
Entity Type:Organization
Organization Name:PROVIDENCE DENTAL SPA OF NEWNAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-550-7741
Mailing Address - Street 1:225 N MACON ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-6562
Mailing Address - Country:US
Mailing Address - Phone:478-733-0857
Mailing Address - Fax:478-254-5709
Practice Address - Street 1:166 JEFFERSON PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5822
Practice Address - Country:US
Practice Address - Phone:770-252-1300
Practice Address - Fax:770-252-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental