Provider Demographics
NPI:1801069240
Name:JAMESTOWN CONDOTTIERE IMPLANT&GENERAL DENTISTRY CTR. P.C.
Entity type:Organization
Organization Name:JAMESTOWN CONDOTTIERE IMPLANT&GENERAL DENTISTRY CTR. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALDOUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-767-9356
Mailing Address - Street 1:2457 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350
Mailing Address - Country:US
Mailing Address - Phone:404-767-9356
Mailing Address - Fax:404-529-4465
Practice Address - Street 1:2457 RIVERDALE RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-5003
Practice Address - Country:US
Practice Address - Phone:404-767-9356
Practice Address - Fax:404-529-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO119471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00809025BMedicaid