Provider Demographics
NPI:1780832386
Name:VILLA RICA FAMILY DENTAL
Entity Type:Organization
Organization Name:VILLA RICA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-459-4131
Mailing Address - Street 1:865 S CARROLL RD STE C
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7056
Mailing Address - Country:US
Mailing Address - Phone:770-459-4131
Mailing Address - Fax:770-459-4132
Practice Address - Street 1:865 S CARROLL RD STE C
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7056
Practice Address - Country:US
Practice Address - Phone:770-459-4131
Practice Address - Fax:770-459-4132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN01125591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA129648207AMedicaid