=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528422524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOVERNMENT DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2016
-----------------------------------------------------
Last Update Date | 05/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7218 HIGHWAY 85
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-593-3404
-----------------------------------------------------
Fax | 404-228-9673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7218 HIGHWAY 85
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-593-3404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. FRANCINE WEATHERSPOON DIXON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-256-2638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14566GA
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------