Healthcare Provider Details

I. General information

NPI: 1023476652
Provider Name (Legal Business Name): JOHN AND PAUL DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 PIERCE AVE
MACON GA
31204-2871
US

IV. Provider business mailing address

160 PIERCE AVE
MACON GA
31204-2871
US

V. Phone/Fax

Practice location:
  • Phone: 478-743-0901
  • Fax:
Mailing address:
  • Phone: 478-743-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013328
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012737
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN007573
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN013383
License Number StateGA

VIII. Authorized Official

Name: MRS. TINA LOCHER
Title or Position: OFFICE MANAGER
Credential:
Phone: 478-743-0901