MEDICARE: GEORGIA DENTAL PROFESSIONALS, PC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1780220194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DENTAL PROFESSIONALS, PC

Provider Business Mailing Address
First Line	:	4355 TOWNE LAKE PKWY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-8150
Country	:	US
Telephone Number	:	770-627-0319
Fax Number	:	770-639-2464

Provider Business Practice Location Address
First Line	:	4355 TOWNE LAKE PKWY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-8150
Country	:	US
Telephone Number	:	678-905-0211
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	JESSICA BRITT
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	11/20/2019
Last Update Date	:	03/11/2020

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