Provider Demographics
NPI:1184095374
Name:AFFORDABLE DENTIST OF SNELLVILLE GA, LLC
Entity type:Organization
Organization Name:AFFORDABLE DENTIST OF SNELLVILLE GA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-383-5784
Mailing Address - Street 1:PO BOX 191363
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31119-1363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2138 SCENIC HWY N
Practice Address - Street 2:STE D
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6106
Practice Address - Country:US
Practice Address - Phone:770-985-2325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010714122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty