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	:	1790662682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DENTAL PROFESSIONALS, PC

Provider Business Mailing Address
First Line	:	2795 LEE RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-3358
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2795 LEE RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-3358
Country	:	US
Telephone Number	:	470-750-1330
Fax Number	:	470-750-1340

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	HILLARY THULL
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	08/20/2025

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