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General NPI Number Information
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NPI Number | 1073083127
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF CENTRAL GEORGIA - MACON LLC
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Dates
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Enumeration Date | 12/03/2018
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Last Update Date | 12/03/2018
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Provider Practice Location Address
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Address Line | 5437 BOWMAN RD STE 300
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City | MACON
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State | GA
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Zip | 31210-6575
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Country | US
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Telephone | 478-333-3636
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Fax |
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Provider Business Mailing Address
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Address Line | 900 PROFESSIONAL DR
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City | WARNER ROBINS
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State | GA
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Zip | 31088-0520
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Country | US
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Telephone | 478-333-3636
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. SHANNON BATTLE
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Credential |
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Telephone | 478-333-3636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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