Healthcare Provider Details

I. General information

NPI: 1831954304
Provider Name (Legal Business Name): CLIFFORD AVENUE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CLIFFORD AVE
SYLVANIA GA
30467-2012
US

IV. Provider business mailing address

112 CLIFFORD AVE
SYLVANIA GA
30467-2012
US

V. Phone/Fax

Practice location:
  • Phone: 912-564-7107
  • Fax: 912-564-9349
Mailing address:
  • Phone: 912-564-7107
  • Fax: 912-564-9349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNY GARCIA-ROCHA
Title or Position: SR TEAM LEAD
Credential:
Phone: 972-869-3789