Healthcare Provider Details

I. General information

NPI: 1477096832
Provider Name (Legal Business Name): PCP DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 DAWSONVILLE HWY STE F
GAINESVILLE GA
30501-2607
US

IV. Provider business mailing address

PO BOX 3189
SYRACUSE NY
13220-3189
US

V. Phone/Fax

Practice location:
  • Phone: 678-928-3219
  • Fax: 770-532-6391
Mailing address:
  • Phone: 315-454-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER LA DUC
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 315-454-6000