Provider Demographics
NPI:1902017270
Name:PEACH FAMILY DENTISTRY,LLC
Entity Type:Organization
Organization Name:PEACH FAMILY DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWSON
Authorized Official - Middle Name:KENDRICK
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-825-3315
Mailing Address - Street 1:302 KNOXVILLE ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-4251
Mailing Address - Country:US
Mailing Address - Phone:478-825-3315
Mailing Address - Fax:478-825-8396
Practice Address - Street 1:302 KNOXVILLE ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-4251
Practice Address - Country:US
Practice Address - Phone:478-825-3315
Practice Address - Fax:478-825-8396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0082831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty