Provider Demographics
NPI:1851729883
Name:AVALA DENTAL PROVIDERS,LLC
Entity Type:Organization
Organization Name:AVALA DENTAL PROVIDERS,LLC
Other - Org Name:POLISH DENTAL CENTER,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:N
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-696-4144
Mailing Address - Street 1:629 A BEAVER RUIN RD
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-696-4144
Mailing Address - Fax:470-545-2859
Practice Address - Street 1:629 A BEAVER RUIN RD
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-696-4144
Practice Address - Fax:470-545-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014034305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1487953741Medicaid