Provider Demographics
NPI:1952314080
Name:BABB, BRIAN R (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BABB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 OAKHURST DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:706-863-9490
Mailing Address - Fax:706-863-9420
Practice Address - Street 1:805 OAKHURST DR.
Practice Address - Street 2:SUITE B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-863-9490
Practice Address - Fax:706-863-9420
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130981223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA488375310AMedicaid