Provider Demographics
NPI:1932754223
Name:CCSD-DACULA, LLC
Entity Type:Organization
Organization Name:CCSD-DACULA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-1957
Mailing Address - Street 1:420 DACULA RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2128
Mailing Address - Country:US
Mailing Address - Phone:770-277-0800
Mailing Address - Fax:
Practice Address - Street 1:420 DACULA RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2128
Practice Address - Country:US
Practice Address - Phone:770-277-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental