Provider Demographics
NPI:1780220194
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:DENTAL CARE AT ROSE CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:4355 TOWNE LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8150
Mailing Address - Country:US
Mailing Address - Phone:770-627-0319
Mailing Address - Fax:770-639-2464
Practice Address - Street 1:4355 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8150
Practice Address - Country:US
Practice Address - Phone:678-905-0211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-20
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty