Provider Demographics
NPI:1821103086
Name:NEAL, DONALD C JR (DMD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:C
Last Name:NEAL
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4146
Mailing Address - Country:US
Mailing Address - Phone:706-884-2655
Mailing Address - Fax:706-883-7670
Practice Address - Street 1:1587 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4146
Practice Address - Country:US
Practice Address - Phone:706-884-2655
Practice Address - Fax:706-883-7670
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0102311223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000399605AMedicaid
GA000399605AMedicaid
GAU16830Medicare UPIN