Healthcare Provider Details

I. General information

NPI: 1396882783
Provider Name (Legal Business Name): ALLRED DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 09/16/2016
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 S 8TH ST
GRIFFIN GA
30224-4818
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-6101
  • Fax: 770-228-6170
Mailing address:
  • Phone: 770-228-6101
  • Fax: 770-228-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number010469
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number014094
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number014960
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number014067
License Number StateGA

VIII. Authorized Official

Name: SHELLI ANNE CARROLL
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-741-8433