Provider Demographics
NPI:1992861637
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity Type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:755 COMMERCE DR
Mailing Address - Street 2:SUITE 513
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2627
Mailing Address - Country:US
Mailing Address - Phone:404-377-7711
Mailing Address - Fax:404-377-6040
Practice Address - Street 1:755 COMMERCE DR
Practice Address - Street 2:SUITE 513
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2627
Practice Address - Country:US
Practice Address - Phone:404-377-7711
Practice Address - Fax:404-377-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1922164672OtherDR. THOMAS J. PRICE