MEDICARE: AESTHETIC DENTAL ASSOC OF NE GA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN007721	GA

General Provider Information

NPI Number	:	1457793895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC DENTAL ASSOC OF NE GA LLC

Provider Business Mailing Address
First Line	:	1520A JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-353-1958
Fax Number	:	706-353-3939

Provider Business Practice Location Address
First Line	:	1520A JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-353-1958
Fax Number	:	706-353-3939

Authorized Official
Title or Position	:	OWNER
Name	:	R. LAWRENCE GEORGE
Credential	:	DMD
Telephone Number	:	706-353-1958

Provider Enumeration Date	:	07/26/2013
Last Update Date	:	07/26/2013

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