Provider Demographics
NPI:1831773233
Name:GEORGIA DENTAL PROFESSIONALS, PC
Entity type:Organization
Organization Name:GEORGIA DENTAL PROFESSIONALS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:1200 ERNEST W BARRETT PKWY NW STE 200
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 ERNEST W BARRETT PKWY NW STE 200
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4513
Practice Address - Country:US
Practice Address - Phone:678-354-0079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL PROFESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty