Provider Demographics
NPI:1770970915
Name:WESTSIDE MANAGEMENT
Entity type:Organization
Organization Name:WESTSIDE MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRYL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ODONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-499-7005
Mailing Address - Street 1:3515 DALLAS HWY STE. B
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:770-499-7005
Mailing Address - Fax:770-499-7081
Practice Address - Street 1:3515 DALLAS HWY STE. B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
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:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65978OtherDELTA DENTAL OF GA.