Healthcare Provider Details

I. General information

NPI: 1679551790
Provider Name (Legal Business Name): GEORGIA DENTAL OUTREACH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 LAKEFIELD CT SE STE A
CONYERS GA
30013-6609
US

IV. Provider business mailing address

1816 LAKEFIELD CT SE STE A
CONYERS GA
30013-6609
US

V. Phone/Fax

Practice location:
  • Phone: 888-833-8441
  • Fax: 888-373-9612
Mailing address:
  • Phone: 888-833-8441
  • Fax: 888-373-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAUL SPURGEON
Title or Position: CREDENTIALING
Credential:
Phone: 888-833-8441