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General NPI Number Information
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NPI Number | 1275898900
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Entity Type | Organization
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Legal Business Name | DYESS PARKWAY DENTAL, LLC
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 4045 JIMMIE DYESS PKWY STE 103
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City | AUGUSTA
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State | GA
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Zip | 30909-9492
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Country | US
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Telephone | 706-868-4200
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Fax | 706-868-4717
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Provider Business Mailing Address
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Address Line | 4045 JIMMIE DYESS PKWY STE 103
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City | AUGUSTA
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State | GA
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Zip | 30909-9492
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Country | US
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Telephone | 706-868-4200
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Fax | 706-868-4717
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Authorized Official
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Title or Position | DENTIST
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Name | DR. FRED M HANNAN SR.
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Credential | D.D.S.
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Telephone | 706-868-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6539
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License Number State | GA
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