Healthcare Provider Details

I. General information

NPI: 1073245437
Provider Name (Legal Business Name): JOSEPH CHANDLER ENTREKIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2022
Last Update Date: 06/25/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 LAUREL ST
BREMEN GA
30110-2124
US

IV. Provider business mailing address

501 VALLEY RUN DR
BREMEN GA
30110-2411
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-4439
  • Fax:
Mailing address:
  • Phone: 770-537-3574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122693
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: