Healthcare Provider Details

I. General information

NPI: 1114181138
Provider Name (Legal Business Name): GAINESVILLE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 05/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 SPRING ST
GAINESVILLE GA
30501
US

IV. Provider business mailing address

426 SPRING ST
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-0401
  • Fax: 770-297-8477
Mailing address:
  • Phone: 770-297-0401
  • Fax: 770-297-8477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN11839
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN013644
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013665
License Number StateKY

VIII. Authorized Official

Name: PAUL E. GANNON
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 770-297-0401