Healthcare Provider Details

I. General information

NPI: 1629073465
Provider Name (Legal Business Name): ERIC D FERRARA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 S 8TH ST
GRIFFIN GA
30224-4214
US

IV. Provider business mailing address

614 S 8TH ST
GRIFFIN GA
30224-4214
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-1010
  • Fax: 678-692-0242
Mailing address:
  • Phone: 770-228-1010
  • Fax: 678-692-0242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN013416
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN013416
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013416
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDN013416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: