Provider Demographics
NPI:1871012740
Name:GEORGIA MOUNTAINS HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:GEORGIA MOUNTAINS HEALTH SERVICES, INC.
Other - Org Name:SUPER FRIENDLY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRACLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-946-5610
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5607
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:80 CINEMA DRIVE
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-2592
Practice Address - Country:US
Practice Address - Phone:706-276-2828
Practice Address - Fax:706-276-2826
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA MOUNTAINS HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003200832AMedicaid