Provider Demographics
NPI:1790190056
Name:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Entity Type:Organization
Organization Name:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Other - Org Name:LITTLE RIVER FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:12201 HIGHWAY 92
Mailing Address - Street 2:SUITE G/H
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12201 HIGHWAY 92
Practice Address - Street 2:SUITE G/H
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7140
Practice Address - Country:US
Practice Address - Phone:678-348-6858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL CARE OF GEORGIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty