Provider Demographics
NPI:1134405848
Name:EAGLIN DENTAL GROUP, FAYETTEVILLE
Entity type:Organization
Organization Name:EAGLIN DENTAL GROUP, FAYETTEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-716-2701
Mailing Address - Street 1:692 GLYNN ST N STE S
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6705
Mailing Address - Country:US
Mailing Address - Phone:770-716-2701
Mailing Address - Fax:770-716-2718
Practice Address - Street 1:692 GLYNN ST N STE S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-6705
Practice Address - Country:US
Practice Address - Phone:770-716-2701
Practice Address - Fax:770-716-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131691223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA777472578DMedicaid