Provider Demographics
NPI:1457793895
Name:AESTHETIC DENTAL ASSOC OF NE GA LLC
Entity Type:Organization
Organization Name:AESTHETIC DENTAL ASSOC OF NE GA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R.
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-353-1958
Mailing Address - Street 1:1520A JENNINGS MILL RD
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2543
Mailing Address - Country:US
Mailing Address - Phone:706-353-1958
Mailing Address - Fax:706-353-3939
Practice Address - Street 1:1520A JENNINGS MILL RD
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2543
Practice Address - Country:US
Practice Address - Phone:706-353-1958
Practice Address - Fax:706-353-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN007721122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty