Healthcare Provider Details

I. General information

NPI: 1508794231
Provider Name (Legal Business Name): GEORGIA DENTAL PROFESSIONALS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 HIGHWAY 42 S
LOCUST GROVE GA
30248-4111
US

IV. Provider business mailing address

4550 HIGHWAY 42 S
LOCUST GROVE GA
30248-4111
US

V. Phone/Fax

Practice location:
  • Phone: 470-994-7810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: CEMYIRA MCDOUGAL
Title or Position: CREDENTIALING
Credential:
Phone: 217-764-8609