Healthcare Provider Details

I. General information

NPI: 1174984165
Provider Name (Legal Business Name): ERIC BAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 NELSON BROGDON BLVD
BUFORD GA
30518
US

IV. Provider business mailing address

4740 NELSON BROGDON BLVD
BUFORD GA
30518-3480
US

V. Phone/Fax

Practice location:
  • Phone: 770-945-5027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN015388
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: