Provider Demographics
NPI:1508813031
Name:DENTAL SLEEP MEDICINE OF GA PC
Entity type:Organization
Organization Name:DENTAL SLEEP MEDICINE OF GA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:WARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-546-8407
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2188
Mailing Address - Country:US
Mailing Address - Phone:706-546-8407
Mailing Address - Fax:706-546-8409
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 2300
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2188
Practice Address - Country:US
Practice Address - Phone:706-546-8407
Practice Address - Fax:706-546-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0080981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5077OtherGROUP #
GA4566050001Medicare NSC