Provider Demographics
NPI:1457427064
Name:FAMILY DENTISTRY OF COLUMBUS PC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF COLUMBUS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-563-5516
Mailing Address - Street 1:3408 UNIVERSITY AVE
Mailing Address - Street 2:STE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907
Mailing Address - Country:US
Mailing Address - Phone:706-563-5516
Mailing Address - Fax:706-563-5575
Practice Address - Street 1:3408 UNIVERSITY AVE
Practice Address - Street 2:STE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907
Practice Address - Country:US
Practice Address - Phone:706-563-5516
Practice Address - Fax:706-563-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
980348OtherUNITED CONCORDIA