=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366128936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADFC-WATKINSVILLE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2023
-----------------------------------------------------
Last Update Date | 06/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1355 RESURGENCE DR
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-7306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-355-3109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1355 RESURGENCE DR
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-7306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING LEAD
-----------------------------------------------------
Name | JENNY GARCIA-ROCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------