Provider Demographics
NPI:1750346102
Name:JIMMY F MAXWELL DMD PC
Entity type:Organization
Organization Name:JIMMY F MAXWELL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:FOSTER
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PC
Authorized Official - Phone:229-246-3023
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:500 AMELIA AVENUE
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39818-0727
Mailing Address - Country:US
Mailing Address - Phone:229-246-3023
Mailing Address - Fax:229-246-3024
Practice Address - Street 1:500 AMELIA AVENUE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39818-0727
Practice Address - Country:US
Practice Address - Phone:229-246-3023
Practice Address - Fax:229-246-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9728122300000X
TNDS0000007704122300000X
GADN009648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPHO11407OtherGEORGIA BOARD OF PHARMACY
GA00245341A4Medicaid