Provider Demographics
NPI:1912767039
Name:FAMILY DENTISTRY OF BLAIRSVILLE, LLC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF BLAIRSVILLE, LLC
Other - Org Name:FAMILY DENTISTRY OF BLAIRSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-665-0178
Mailing Address - Street 1:100 WESLEY MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8338
Mailing Address - Country:US
Mailing Address - Phone:706-745-7100
Mailing Address - Fax:
Practice Address - Street 1:100 WESLEY MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8338
Practice Address - Country:US
Practice Address - Phone:706-745-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment