Provider Demographics
NPI:1649660473
Name:MACON GA ORTHODONTICS
Entity type:Organization
Organization Name:MACON GA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:HOLLAND
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-746-7686
Mailing Address - Street 1:3312 NORTHSIDE DR
Mailing Address - Street 2:BUILDING B # 150
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2500
Mailing Address - Country:US
Mailing Address - Phone:478-746-7686
Mailing Address - Fax:478-254-3870
Practice Address - Street 1:3312 NORTHSIDE DR
Practice Address - Street 2:BUILDING B # 150
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2500
Practice Address - Country:US
Practice Address - Phone:478-746-7686
Practice Address - Fax:478-254-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty