Healthcare Provider Details

I. General information

NPI: 1487807434
Provider Name (Legal Business Name): LAGRANGE FAMILY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S GREENWOOD ST
LAGRANGE GA
30240-3128
US

IV. Provider business mailing address

PO BOX 2030
LAGRANGE GA
30241-0042
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-5551
  • Fax: 706-812-8558
Mailing address:
  • Phone: 706-882-5551
  • Fax: 706-812-8558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8745
License Number StateGA

VIII. Authorized Official

Name: MR. GEORGE W BAKER JR.
Title or Position: OWNER
Credential: D.M.D
Phone: 706-882-5551