Provider Demographics
NPI:1437995503
Name:PROVIDENCE DENTAL LLC
Entity type:Organization
Organization Name:PROVIDENCE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-733-0857
Mailing Address - Street 1:555 SUN VALLEY DR STE C3
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5621
Mailing Address - Country:US
Mailing Address - Phone:770-643-9499
Mailing Address - Fax:770-490-9499
Practice Address - Street 1:225 N MACON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-6562
Practice Address - Country:US
Practice Address - Phone:478-733-0857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental