Provider Demographics
NPI:1487293882
Name:GEORGIA DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:GEORGIA DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTIVE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-313-5083
Mailing Address - Street 1:P O DRAWER 877
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750
Mailing Address - Country:US
Mailing Address - Phone:229-423-7974
Mailing Address - Fax:
Practice Address - Street 1:320 BENJAMIN H HILL DR SW
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8694
Practice Address - Country:US
Practice Address - Phone:229-423-7974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DENTAL ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-02
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental