Healthcare Provider Details

I. General information

NPI: 1851493977
Provider Name (Legal Business Name): PHILLIP HUE DURDEN IV D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MOORES GROVE RD
WINTERVILLE GA
30683-1506
US

IV. Provider business mailing address

104 MOORES GROVE RD
WINTERVILLE GA
30683-1506
US

V. Phone/Fax

Practice location:
  • Phone: 706-742-7000
  • Fax: 706-742-2145
Mailing address:
  • Phone: 706-742-7000
  • Fax: 706-742-2145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN010773
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: