Healthcare Provider Details

I. General information

NPI: 1235635715
Provider Name (Legal Business Name): WINTERVILLE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP HUE DURDEN IV
Title or Position: MEMBER
Credential: DMD
Phone: 706-742-7000