Healthcare Provider Details

I. General information

NPI: 1083799266
Provider Name (Legal Business Name): MICHAEL RAY CALLAHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12991 JONES ST
LAVONIA GA
30553-1158
US

IV. Provider business mailing address

PO BOX 736 12991 JONES STREET
LAVONIA GA
30553-0736
US

V. Phone/Fax

Practice location:
  • Phone: 706-356-1477
  • Fax: 706-356-7070
Mailing address:
  • Phone: 706-356-1477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10836
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: