Provider Demographics
NPI:1174984165
Name:BAILEY, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 NELSON BROGDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4740 NELSON BROGDON BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:770-945-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0153881223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty