Provider Demographics
NPI:1831355122
Name:CASTOR, ERIC A (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:CASTOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-5716
Mailing Address - Country:US
Mailing Address - Phone:229-482-1100
Mailing Address - Fax:229-482-1103
Practice Address - Street 1:121 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-1314
Practice Address - Country:US
Practice Address - Phone:229-482-1100
Practice Address - Fax:229-482-1103
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA426342256AMedicaid