MEDICARE: LOGANVILLE DENTAL ASSOCIATES

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	:	1154682219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGANVILLE DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	150 HIGHWAY 78
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2277
Country	:	US
Telephone Number	:	770-466-0580
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 HIGHWAY 78
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2277
Country	:	US
Telephone Number	:	770-466-0580
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JANE HAMMOND
Credential	:
Telephone Number	:	770-466-0580

Provider Enumeration Date	:	06/06/2012
Last Update Date	:	06/06/2012

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