Healthcare Provider Details

I. General information

NPI: 1457606881
Provider Name (Legal Business Name): MACON PERIODONTICS AND IMPLANT DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 HARDEMAN AVE
MACON GA
31201-1162
US

IV. Provider business mailing address

1923 HARDEMAN AVE
MACON GA
31201-1162
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-4254
  • Fax: 478-742-1457
Mailing address:
  • Phone: 478-742-4254
  • Fax: 478-742-1457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MS. KAY WILLIS
Title or Position: BUSINESS COORDINATOR
Credential:
Phone: 478-742-4254