Healthcare Provider Details

I. General information

NPI: 1003296633
Provider Name (Legal Business Name): ALLRED FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 S 8TH ST
GRIFFIN GA
30224-4818
US

IV. Provider business mailing address

743 SOUTH 8TH STREET
GRIFFIN GA
30224
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-6101
  • Fax:
Mailing address:
  • Phone: 770-228-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN014960
License Number StateGA

VIII. Authorized Official

Name: MARC BRANDON ALLRED
Title or Position: PART OWNER
Credential: DMD
Phone: 770-946-3576