Provider Demographics
NPI:1487953741
Name:AVALA DENTAL PROVIDERS
Entity type:Organization
Organization Name:AVALA DENTAL PROVIDERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-714-8433
Mailing Address - Street 1:5495 JIMMY CARTER BLVD.
Mailing Address - Street 2:SUITE A-14
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5495 JIMMY CARTER BLVD.
Practice Address - Street 2:SUITE A-14
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:770-368-9159
Practice Address - Fax:770-368-9119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORT DENTAL LOUNGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-24
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0140341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty