Provider Demographics
NPI:1821383035
Name:DOTHAN COSMETIC DENTISTRY, PC
Entity Type:Organization
Organization Name:DOTHAN COSMETIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:MATHEWS
Authorized Official - Last Name:GAUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-673-7440
Mailing Address - Street 1:2431 W MAIN ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1217
Mailing Address - Country:US
Mailing Address - Phone:334-673-7440
Mailing Address - Fax:334-673-7528
Practice Address - Street 1:2431 W MAIN ST
Practice Address - Street 2:SUITE 401
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1217
Practice Address - Country:US
Practice Address - Phone:334-673-7440
Practice Address - Fax:334-673-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty