Provider Demographics
NPI:1760706584
Name:EASTMAN FAMILY DENTAL CENTER LLP
Entity Type:Organization
Organization Name:EASTMAN FAMILY DENTAL CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRD
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-374-4716
Mailing Address - Street 1:421 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6749
Mailing Address - Country:US
Mailing Address - Phone:478-374-4716
Mailing Address - Fax:
Practice Address - Street 1:421 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6749
Practice Address - Country:US
Practice Address - Phone:478-374-4716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137431223G0001X
GADN0089891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000281575AMedicaid
GA661860075AMedicaid