Provider Demographics
NPI:1457431496
Name:HICKORY FLAT DENTAL GROUP
Entity Type:Organization
Organization Name:HICKORY FLAT DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-891-0272
Mailing Address - Street 1:7840 HIGHWAY 140
Mailing Address - Street 2:MILL CREEK PROFESSIONAL PARK
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:678-891-0272
Mailing Address - Fax:
Practice Address - Street 1:7840 HIGHWAY 140
Practice Address - Street 2:MILL CREEK PROFESSIONAL PARK
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:678-891-0272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty