Healthcare Provider Details

I. General information

NPI: 1861883043
Provider Name (Legal Business Name): DENTAL SLEEP MEDICINE OF ATHENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MOORES GROVE RD STE 100
WINTERVILLE GA
30683-1506
US

IV. Provider business mailing address

104 MOORES GROVE RD STE 100
WINTERVILLE GA
30683-1506
US

V. Phone/Fax

Practice location:
  • Phone: 706-546-8407
  • Fax: 706-546-8409
Mailing address:
  • Phone: 706-546-8407
  • Fax: 706-546-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number010580
License Number StateGA

VIII. Authorized Official

Name: DR. PHILLIP H DURDEN
Title or Position: MEMBER
Credential: DMD
Phone: 706-740-4000