Provider Demographics
NPI:1780719765
Name:WEST COBB DENTAL GROUP
Entity type:Organization
Organization Name:WEST COBB DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:770-428-5959
Mailing Address - Street 1:1001 WHITLOCK AVE SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1930
Mailing Address - Country:US
Mailing Address - Phone:770-428-5959
Mailing Address - Fax:770-421-2168
Practice Address - Street 1:1001 WHITLOCK AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1930
Practice Address - Country:US
Practice Address - Phone:770-428-5959
Practice Address - Fax:770-421-2168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA440414OtherUNITED CONCORDIA