Provider Demographics
NPI:1396071270
Name:DENTURES AND FAMILY DENTISTRY
Entity type:Organization
Organization Name:DENTURES AND FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-482-7800
Mailing Address - Street 1:1825 ROCKBRIDGE RD
Mailing Address - Street 2:SUITE 14 C
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3335
Mailing Address - Country:US
Mailing Address - Phone:770-482-7800
Mailing Address - Fax:770-482-7830
Practice Address - Street 1:1825 ROCKBRIDGE RD
Practice Address - Street 2:SUITE 14 C
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3335
Practice Address - Country:US
Practice Address - Phone:678-672-2720
Practice Address - Fax:678-672-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN11497302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000749504AMedicaid