MEDICARE: COVINGTON FAMILY DENTISTRY 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	10491	GA

General Provider Information

NPI Number	:	1861738973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVINGTON FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	4168 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1404
Country	:	US
Telephone Number	:	770-787-2230
Fax Number	:

Provider Business Practice Location Address
First Line	:	4168 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1404
Country	:	US
Telephone Number	:	770-787-2230
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN RAYMOND HENDRICKS JR.
Credential	:	DDS
Telephone Number	:	404-375-7326

Provider Enumeration Date	:	12/17/2012
Last Update Date	:	12/17/2012

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