Provider Demographics
NPI:1245507292
Name:EAGLIN DENTAL GROUP, JOHNS CREEK
Entity type:Organization
Organization Name:EAGLIN DENTAL GROUP, JOHNS CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:S
Authorized Official - Last Name:EAGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-418-1777
Mailing Address - Street 1:6290 ABBOTTS BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1750
Mailing Address - Country:US
Mailing Address - Phone:770-418-1777
Mailing Address - Fax:678-646-5982
Practice Address - Street 1:6290 ABBOTTS BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1750
Practice Address - Country:US
Practice Address - Phone:770-418-1777
Practice Address - Fax:678-646-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
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