Healthcare Provider Details

I. General information

NPI: 1699299545
Provider Name (Legal Business Name): GREENCASTLE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 GREENCASTLE RD
TYRONE GA
30290-2938
US

IV. Provider business mailing address

195 GREENCASTLE RD
TYRONE GA
30290-2938
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-5585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA HOLLY COPE
Title or Position: FRONT OFFICE
Credential:
Phone: 770-486-5585