Provider Demographics
NPI:1942738901
Name:LOCAL DENTAL PARTNERS, LLC
Entity Type:Organization
Organization Name:LOCAL DENTAL PARTNERS, LLC
Other - Org Name:WALTON CENTER FOR FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NICHELLE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-450-2030
Mailing Address - Street 1:4353 ATLANTA HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3232
Mailing Address - Country:US
Mailing Address - Phone:770-405-2030
Mailing Address - Fax:
Practice Address - Street 1:4353 ATLANTA HIGHWAY SUITE. 300
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052
Practice Address - Country:US
Practice Address - Phone:770-405-2030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOCAL DENTAL PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-02
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013645261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicaid