=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710522065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA DENTAL ALLIANCE OF GREENSBORO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2019
-----------------------------------------------------
Last Update Date | 02/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 COWLES CLINC WAY STE W-200
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30642-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-454-0044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 COWLES CLINC WAY STE W-200
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30642-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-454-0044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | JENNI TOMLINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-986-7116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------