Provider Demographics
NPI:1205501020
Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF GEORGIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:345 N BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3096
Mailing Address - Country:US
Mailing Address - Phone:706-650-2285
Mailing Address - Fax:
Practice Address - Street 1:345 N BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3096
Practice Address - Country:US
Practice Address - Phone:706-650-2285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty