Provider Demographics
NPI:1649486028
Name:WESTSIDE DENTAL
Entity type:Organization
Organization Name:WESTSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-499-7005
Mailing Address - Street 1:3515 DALLAS HWY SW STE B
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1613
Mailing Address - Country:US
Mailing Address - Phone:770-499-7005
Mailing Address - Fax:770-499-7081
Practice Address - Street 1:3515 DALLAS HWY SW STE B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1613
Practice Address - Country:US
Practice Address - Phone:770-499-7005
Practice Address - Fax:770-499-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty