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General NPI Number Information
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NPI Number | 1134405848
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Entity Type | Organization
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Legal Business Name | EAGLIN DENTAL GROUP, FAYETTEVILLE
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Dates
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Enumeration Date | 10/26/2011
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 692 GLYNN ST N STE S
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-6705
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Country | US
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Telephone | 770-716-2701
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Fax | 770-716-2718
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Provider Business Mailing Address
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Address Line | 692 GLYNN ST N STE S
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-6705
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Country | US
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Telephone | 770-716-2701
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Fax | 770-716-2718
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Authorized Official
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Title or Position | OWNER
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Name | MRS. TRACIE DENNEY
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Credential |
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Telephone | 770-716-2701
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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 | DN013169
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN013169
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License Number State | GA
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