Healthcare Provider Details

I. General information

NPI: 1225798929
Provider Name (Legal Business Name): PROGRESSIVE DG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 PARK CENTRAL BLVD STE 3
DECATUR GA
30035-3903
US

IV. Provider business mailing address

2485 PARK CENTRAL BLVD STE 3
DECATUR GA
30035-3903
US

V. Phone/Fax

Practice location:
  • Phone: 770-593-4976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. AUNDREA EADY
Title or Position: OWNER
Credential: DMD
Phone: 305-479-7602