Healthcare Provider Details

I. General information

NPI: 1215891049
Provider Name (Legal Business Name): GA SOUTHERN DENTAL PPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7407 N LAKE LOOP
COLUMBUS GA
31909-2577
US

IV. Provider business mailing address

5830 GRANITE PKWY STE 780
PLANO TX
75024-6775
US

V. Phone/Fax

Practice location:
  • Phone: 706-323-8811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ERIKA MENJIVAR
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 469-596-6137