Provider Demographics
NPI:1760870885
Name:SPECIAL CARE DENTAL OF GEORGIA
Entity Type:Organization
Organization Name:SPECIAL CARE DENTAL OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:855-259-9183
Mailing Address - Street 1:12910 SHELBYVILLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2404
Mailing Address - Country:US
Mailing Address - Phone:502-244-2441
Mailing Address - Fax:502-254-4086
Practice Address - Street 1:111 JOHN MADDOX DR NW
Practice Address - Street 2:STE. 128
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:855-259-9183
Practice Address - Fax:502-254-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty