Healthcare Provider Details

I. General information

NPI: 1558223461
Provider Name (Legal Business Name): COUNTRYSIDE DENTAL - LAGRANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2025
Last Update Date: 11/29/2025
Certification Date: 11/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHURCH ST FL 1
LAGRANGE GA
30240-2700
US

IV. Provider business mailing address

307 CHURCH ST FL 1
LAGRANGE GA
30240-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-3263
  • Fax: 706-884-3263
Mailing address:
  • Phone: 706-884-3263
  • Fax: 706-884-3263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: YOKECA NICOLE WATTS
Title or Position: DENTIST, PARTNER
Credential: DMD
Phone: 205-563-9877