=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568399939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA DENTAL PROFESSIONALS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2026
-----------------------------------------------------
Last Update Date | 05/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 GAINES SCHOOL RD
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30605-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-316-2450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 GAINES SCHOOL RD
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30605-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | CEMYIRA MCDOUGAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-764-8609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------