Provider Demographics
NPI:1689118127
Name:COWETA DENTISTRY SDA PC
Entity Type:Organization
Organization Name:COWETA DENTISTRY SDA PC
Other - Org Name:COWETA DENTISTRY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-410-1340
Mailing Address - Street 1:15 RUTH DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2317
Mailing Address - Country:US
Mailing Address - Phone:770-253-3171
Mailing Address - Fax:770-253-9892
Practice Address - Street 1:15 RUTH DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2317
Practice Address - Country:US
Practice Address - Phone:770-253-3171
Practice Address - Fax:770-253-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty