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General NPI Number Information
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NPI Number | 1831954304
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Entity Type | Organization
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Legal Business Name | CLIFFORD AVENUE DENTAL LLC
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Dates
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Enumeration Date | 02/14/2024
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Last Update Date | 02/14/2024
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Provider Practice Location Address
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Address Line | 112 CLIFFORD AVE
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City | SYLVANIA
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State | GA
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Zip | 30467-2012
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Country | US
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Telephone | 912-564-7107
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Fax | 912-564-9349
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Provider Business Mailing Address
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Address Line | 112 CLIFFORD AVE
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City | SYLVANIA
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State | GA
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Zip | 30467-2012
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Country | US
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Telephone | 912-564-7107
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Fax | 912-564-9349
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Authorized Official
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Title or Position | SR TEAM LEAD
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Name | JENNY GARCIA-ROCHA
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Credential |
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Telephone | 972-869-3789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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