MEDICARE: GEORGIA DENTAL ALLIANCE OF COLUMBUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1053956771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DENTAL ALLIANCE OF COLUMBUS

Provider Business Mailing Address
First Line	:	6410 W HAMILTON PARK DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6410 W HAMILTON PARK DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3004
Country	:	US
Telephone Number	:	706-653-8700
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	CHRISTOPHER SIMS
Credential	:
Telephone Number	:	470-552-1823

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	11/18/2019

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