Provider Demographics
NPI:1710131545
Name:COLEMAN DENTAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:COLEMAN DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-523-3153
Mailing Address - Street 1:970 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-2962
Mailing Address - Country:US
Mailing Address - Phone:404-523-3153
Mailing Address - Fax:404-523-0136
Practice Address - Street 1:970 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE 301
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30314-2962
Practice Address - Country:US
Practice Address - Phone:404-523-3153
Practice Address - Fax:404-523-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0103071223G0001X
GADN0131271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA692906293AMedicaid
GA000364823AMedicaid