Provider Demographics
NPI:1922420074
Name:PEDIATRIC DENTISTRY OF CENTRAL GA, PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CENTRAL GA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-333-3636
Mailing Address - Street 1:900 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-0520
Mailing Address - Country:US
Mailing Address - Phone:478-333-3636
Mailing Address - Fax:478-333-6399
Practice Address - Street 1:900 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-0520
Practice Address - Country:US
Practice Address - Phone:478-333-3636
Practice Address - Fax:478-333-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty