Provider Demographics
NPI:1922357425
Name:DENTAL ASSOCIATES OF MIDDLE GEORGIA, LLC
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF MIDDLE GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-956-4278
Mailing Address - Street 1:123 GRALAN DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-6344
Mailing Address - Country:US
Mailing Address - Phone:478-956-4278
Mailing Address - Fax:478-956-4278
Practice Address - Street 1:123 GRALAN DR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-6344
Practice Address - Country:US
Practice Address - Phone:478-956-4278
Practice Address - Fax:478-956-4278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0082771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty