Provider Demographics
NPI:1851366462
Name:YOUTH DENTISTRY OF MACON, PC
Entity Type:Organization
Organization Name:YOUTH DENTISTRY OF MACON, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, LEGAL LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ZOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-781-4333
Mailing Address - Street 1:1536 EISENHOWER PKWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-3130
Mailing Address - Country:US
Mailing Address - Phone:478-781-4333
Mailing Address - Fax:478-781-4331
Practice Address - Street 1:1536 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3130
Practice Address - Country:US
Practice Address - Phone:478-781-4333
Practice Address - Fax:478-781-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-18
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1905601OtherUNITED CONCORDIA
GA478300670AMedicaid
GA539109OtherAVESIS