Provider Demographics
NPI:1295888956
Name:ELDER DENTAL GROUP, P.C.
Entity type:Organization
Organization Name:ELDER DENTAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-543-4717
Mailing Address - Street 1:2300 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6004
Mailing Address - Country:US
Mailing Address - Phone:706-543-4717
Mailing Address - Fax:706-543-5091
Practice Address - Street 1:2300 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6004
Practice Address - Country:US
Practice Address - Phone:706-543-4717
Practice Address - Fax:706-543-5091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN00795261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental