Provider Demographics
NPI:1023117561
Name:WASHBURN, CHANCEY B C (DMD)
Entity type:Individual
Prefix:DR
First Name:CHANCEY
Middle Name:B C
Last Name:WASHBURN
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 1:410 PEACHTREE PKWY
Mailing Address - Street 2:STE 4204
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7439
Mailing Address - Country:US
Mailing Address - Phone:678-455-4560
Mailing Address - Fax:678-455-9628
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 420
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6012
Practice Address - Country:US
Practice Address - Phone:678-455-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN 012398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000929475AMedicaid