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General NPI Number Information
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NPI Number | 1639641160
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Entity Type | Organization
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Legal Business Name | AMERICAN DENTAL OF FITZGERALD
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Dates
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Enumeration Date | 12/21/2018
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Last Update Date | 12/11/2019
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Provider Practice Location Address
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Address Line | PO BOX 877
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City | FITZGERALD
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State | GA
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Zip | 31750-0877
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Country | US
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Telephone | 229-423-9471
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Fax |
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Provider Business Mailing Address
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Address Line | PO DRAWER 877
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City | FITZGERALD
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State | GA
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Zip | 31750-0877
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Country | US
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Telephone | 229-423-9471
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | VICKI E DAVIS
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Credential |
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Telephone | 229-313-5083
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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