=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275634487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKSIDE DENTAL PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 STEVENS ENTRY
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-487-8882
-----------------------------------------------------
Fax | 770-486-9469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 STEVENS ENTRY PO BOX 2606
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-487-8882
-----------------------------------------------------
Fax | 770-486-9469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHEN L MATLAGA DDS GEN PTR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 770-487-8882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | GA8697
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------