Provider Demographics
NPI:1023321205
Name:PEDIATRIC DENTAL CENTER OF GEORGIA
Entity type:Organization
Organization Name:PEDIATRIC DENTAL CENTER OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUTHER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-238-3787
Mailing Address - Street 1:820 LOVE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4000
Mailing Address - Country:US
Mailing Address - Phone:229-238-3787
Mailing Address - Fax:229-238-2530
Practice Address - Street 1:820 LOVE AVE STE A
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4000
Practice Address - Country:US
Practice Address - Phone:229-238-3787
Practice Address - Fax:229-238-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582837896BMedicaid