Provider Demographics
NPI:1780915165
Name:PINE MOUNTAIN FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:PINE MOUNTAIN FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:DAUSTER
Authorized Official - Last Name:HARDEN
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-663-2272
Mailing Address - Street 1:P.O. BOX 1176
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-4707
Mailing Address - Country:US
Mailing Address - Phone:706-663-2272
Mailing Address - Fax:706-663-2075
Practice Address - Street 1:8944 HAMILTON ROAD
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:31822
Practice Address - Country:US
Practice Address - Phone:706-663-2272
Practice Address - Fax:706-663-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO08005122300000X
GADNO12733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000045295AMedicaid
GA594312970BMedicaid