Provider Demographics
NPI:1710136866
Name:METRO DECATUR DENTAL GROUP
Entity Type:Organization
Organization Name:METRO DECATUR DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-292-3133
Mailing Address - Street 1:4570 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1447
Mailing Address - Country:US
Mailing Address - Phone:404-292-3133
Mailing Address - Fax:404-935-0905
Practice Address - Street 1:4570 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1447
Practice Address - Country:US
Practice Address - Phone:404-292-3133
Practice Address - Fax:404-935-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-13
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA694565025AMedicaid