Healthcare Provider Details

I. General information

NPI: 1215220579
Provider Name (Legal Business Name): EASTMAN DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GRIFFIN AVE
EASTMAN GA
31023-6712
US

IV. Provider business mailing address

P.O. BOX 247
EASTMAN GA
31023
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-7719
  • Fax: 478-374-7044
Mailing address:
  • Phone: 478-374-7719
  • Fax: 478-374-7044

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 Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. CINDY MARIE HENDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 478-374-7719