Provider Demographics
NPI:1972165207
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:DENTAL CARE OF BONAIRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:516 GA HIGHWAY 247 S
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516 GA HIGHWAY 247 S
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3865
Practice Address - Country:US
Practice Address - Phone:478-273-2562
Practice Address - Fax:478-551-4152
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty