Healthcare Provider Details

I. General information

NPI: 1457853210
Provider Name (Legal Business Name): PDA SPECIALTY OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 COBB PKWY NW STE 170
ACWORTH GA
30101-5768
US

IV. Provider business mailing address

11 S MILL ST STE 200
NEW CASTLE PA
16101-3680
US

V. Phone/Fax

Practice location:
  • Phone: 770-203-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE MARLOW
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 724-698-2119